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A  MANUAL 

lZ-~ - 


INFANTILE  PARALYSIS 


MODERN  METHODS  OF  TREATMENT 

INCLUDING 

REPORTS  BASED  ON  THE  TREATMENT  OF 
THREE  THOUSAND  CASES 


HENRY  W.  FRAUENTHAL,  A.C.,M.D. 

SURGEON   AND   PHYSICIAN-IN  -CHIEF,  NKW  YORK   HOSPITAL  FOR  DEFORMITIES  AND 

JOINT  DISEASES 


JACOLYN  VAN  VLIET  MANNING,  M.D. 

EPIDEMIOLOGIST,    WISCONSIN,    1908,    EPIDEMIC    ACUTE    POLIOMYELITIS 


Copiously  Illustrated  With  More  Than  One  Hundred  Engravings 
Nearly  All  Original 


PHILADELPHIA 
F.  A.  DAVIS  COMPANY,  PUBLISHERS 

ENGLISH  DEPOT 
STANLEY  PHILLIPS,  LONDON 

1914 


COPYRIGHT,  1914 

BY 
F.    A.    DAVIS  COMPANY 


Copyright,  Great  Britain.     All  Rights  Reserved 


Philadelphia.  Pa..  U.  S.  A. 

Prets  of    F.  A.   Darii   Company 

1914-16   Cherry  Street 


PREFACE. 


IN  this  volume  we  record  our  personal  experience 
with  acute  poliomyelitis,  its  epidemic  appearance,  symp- 
tomatology, diagnosis,  and  methods  of  treatment.  The 
manual  is  as  free  from  technical  terms  as  is  possible  in 
the  discussion  of  a  disease  whose  lesions  involve  the  nerv- 
«  UTS  system  and  the  intricate  functions  of  the  body  which 
the  nervous  system  initiates,  co-ordinates,  and  directs. 

The  most  recent  publication  on  the  subject  from  the 
Rockefeller  Institute  of  Medical  Research  is  a  monograph 
said  to  be  based  on  the  study  of  161  cases  of  acute  polio- 
myelitis. This  number  of  cases  of  poliomyelitis  is  little 
more  than  the  average  number  of  cases  seen  daily  in  the 
Infantile  Paralysis  Department  of  the  Hospital  for  Defor- 
mities and  Joint  Diseases.  \Ye  regard  the  daily  attendance 
for  treatment  of  100  to  150  children  the  best  testimonial 
from  the  parents  of  the  benefit  derived  by  their  own  chil- 
dren, and  the  children  of  others  who  fall  under  observation 
as  they  await  treatment. 

The  chapters  on  physical  therapy  and  manipulative 
treatment  arc  written  in  plain  language,  that  the  parents 
of  a  case  may  read  what  is  needed  for  a  child,  and  why. 
The  spontaneous  improvement  which  occurs  in  a  certain 
percentage  of  cases  may  be  augmented,  deformities  pre- 
vented, and  cases  with  serious  disability  remedied,  by  the 
reasonable  methods  of  treatment  here  outlined. 

\Ye  have  omitted  reference  to  the  obsolete  and  fre- 
quently misleading  literature  of  the  period  which  antedated 
the  present  pandemic  of  poliomyelitis.  \Ye  have  included 
numerous  clinical  descriptions,  case  reports,  and  autopsies, 

(iii) 


jv  PREFACE. 

consisting  largely  of  cases  of  the  more  obscure  and  hitherto 
unrecognized  variations  of  the  eight  classic  forms  of  the 
disease,  which  have  appeared  in  recent  literature,  and  de- 
sire here  to  express  our  obligation  to  the  several  writers 
on  whose  material  we  have  drawn  to  amplify  and  enhance 
the  value  of  the  manual. 

AYe  wish  also  to  express  our  thanks  to  the  publishers 
and  editors  of  the  medical  journals  in  which  a  part  of  our 
work  has  already  appeared  for  permission  to  reproduce 
some  portions  of  such  articles  here. 

\\  e  desire  especially  to  thank  those  physicians  to  whom 
we  are  indebted  for  personal  reports  of  cases. 

HENRY  W.  FRAUENTHAL, 

783  Lexington  Avenue, 

Xc\v  York  City. 

JACOLYN  VAN  VLIET  MAXNIXC,. 

151  Lafayette  Avenue, 

Brooklyn,  New  York. 


CONTENTS. 


PAGE 

CHAPTER  I.    EPIDEMICS  AND  PANDEMICS  OF  INFANTILE  PARAL- 
YSIS          1 

The  Wisconsin  Epidemic  of  Infantile  Paralysis  in  1908.  1;  Coinci- 
dental Epidemic  Paralysis  in  Animal  and  Man,  7;  a  Table  of  Epi- 
demics and  Pandemics,  16. 

CHAPTER  II.  THE  ETIOLOGY  OR  EXCITING  CAUSE  OF  INFAN- 
TILE PARALYSIS 21 

The  Pleomorphic  Spirochete  of  Rabies,  30;  Successful  Cultivation 
of  the  Pleomorphic  Protozoan  of  Poliomyelitis,  32;  Experimental 
Transmission  to  Monkey,  34;  Method  of  Transmission  of  the 
Micro-organism  of  Acute  Poliomyelitis,  41 ;  Stomoxys  Calcitrans 
(the  Stable-fly;  the  Biting  Fly;  the  Barn-fly;  the  Rain-fly),  42: 
Transmission  of  Poliomyelitis  by  Means  of  the  Stable-fly,  45; 
Cimex  Lectularius  (the  Bedbug;  Chinchbug;  Wall  Louse;  B  Flat;" 
Mahogany  Flat),  48;  Geographic  Range  of  Cimex,  55;  Burden  of 
Proof  that  Cimex  Carries  Poliomyelitis,  55;  Coincidental  Presence 
of  Bedbugs  and  Poliomyelitis,  57;  Contact  Transmission  of  Acute 
Poliomyelitis,  64;  Transmission  of  Acute  Poliomyelitis  through  the 
Dog,  65. 

CHAPTER  III.     PREDISPOSING  CAUSES 69 

Other  Factors  which  May  Increase  Susceptibility  of  Host,  75 ;  Fac- 
tors Increasing  Virulence  of  Virus,  78. 

CHAPTER  IV.     PATHOLOGY 79 

An  Autopsy,  79;  Pathologic  Anatomy,  82;  Meninges  of  Brain  and 
Cord,  84 ;  Cerebrospinal  Fluid,  86 ;  the  Cord,  87 ;  the  Brain,  95 : 
the  Cerebellum,  95;  Cerebrum  and  Central  Ganglia,  97;  Digestive 
System,  98;  the  Spleen,  98;  the  Lungs,  98;  the  Liver,  98;  the 
Kidneys,  99;  the  Blood,  99;  the  Visceral  Lesions,  99;  the  Chronic 
Stage,  101. 

CHAPTER  Y.     GENERAL  SYMPTOMATOLOGY   104 

Incubation,  104;  Aura  of  Attack,  105;  Trauma  Preceding  Polio- 
myelitis, 106;  Onset,  108;  Circulatory  System,  109;  Temperature. 
112;  Respiratory  System,  114;  Digestive  Tract,  116;  Genitourinary 
System,  118:  Cutaneous  System,  119:  Mental  State,  121;  Pain,  123; 

(v) 


vi  CONTEXTS. 

PAGE 

Meningism,  125;  Reflexes,  12(>:  Meningitis,  126:  General  Features 
of  Acute  Attack.  127. 

CHAPTER   \'\.     SYMPTOMATOLOGY  OF  SPECIAL  TYPES  OK  ACTTE 

POLIOMYELITIS 128 

Reclassification  of  Types  of  Poliomyelitis,  128:  the  Arrested  Type, 
130;  the  Spinal  Myelitic  Type,  138;  the  Acute  Ascending  or  Rapidly 
Progressive  Form,  150;  Acute  Bulbar-Pontine  Type  of  Poliomye- 
litis, 154;  Encephalic  Type.  156:  Meningitic  Type,  170;  Xeural  Typo. 
173:  Rapidly  Fatal  Institutional  Disease,  179;  Recrudescence  of 
Poliomyelitis,  184. 

CHAPTER  VII.    DIAGNOSIS  OF  POLIOMYELITIS  ix  THE  PREPARA- 

LYnr  STAGE 186 

Aura  of  Onset,  187 ;  Hyperesthesia,  187 ;  Cervical  Tension,  188 : 
Hyperpyrexia,  190;  Increased  Respiration  Rate,  190;  Increased 
Pulse  Rate,  191 ;  Reflexes  During  Acute  Stage,  192 :  Vomiting,  192 : 
Constipation,  192;  Retention  of  Urine,  193;  Sweating,  Epistaxis,  and 
Cutaneous  Rash,  or  Purpura.  193 :  Examination  of  Spinal  Fluid, 
193:  History  of  Exposure,  194;  Cerebral  Type,  195. 

CHAPTER  VIII.    DIFFERENTIAL  DIAGNOSIS 196 

Meningitis,  1% ;  Epidemic  Cerebrospinal  Meningitis,  198 ;  Suppura- 
tive  Meningitis,  199;  Tuberculous  Meningitis,  199;  Meningism  in 
Infectious  Diseases,  201;  Suppurative  Meningitis,  201;  Other  Dis- 
eases of  the  Cerebrospinal  Axis,  203:  Friedreich's  Ataxia,  204; 
Paralysis  Agitans,  204;  Acute  Transverse  Myelitis,  204;  Diphtheria 
and  Diphtheritic  Paralysis,  205 ;  Syphilitic  Pseudoparalysis,  205 ; 
Tuberculous  Spondylitis  With  Paralysis,  206;  Obstetrical  Paralysis, 
206;  Hysterical  Paralysis,  207;  Pseudoparalysis  of  Scurvy,  207; 
Acute  Infectious  Diseases  Without  Paralysis,  207;  Summer  Diar- 
rhea, 207;  Paratyphoid,  209;  Rheumatism,  209:  Muscular  Rheuma- 
tism, 210;  Tonsillitis,  210;  Influenza,  211;  Pneumonia,  Broncho- 
pneumonia,  211;  Measles,  German  Measles,.  Scarlet  Fever.  Chicken- 
pox,  211;  Tetanus  With  Convulsions,  213;  Rabies,  214;  Dentition, 
Autointoxication,  Ptomaine  Poisoning,  Eclampsia,  Trichiniasis,  215. 

CH Ai'iKR  IX.     PROGNOSIS  IN  ACUTE  EPIDEMIC  POLIOMYELITIS 

AS  TO  LIFE  AND  DISABILITY 221 

Sporadic  Cases,  226;  Paralysis,  Impending.  Progressive,  and 
Regressive,  226;  Residual  Paralysis,  229;  Arrest  of  Growth  of  Long 
Bones  and  Amount  of  Shortening,  231 ;  Atrophy,  Hypertrophy, 
Time  of  Recovery,  232. 


CONTEXTS.  vij 

PAGE 

CHAPTER  X.  PROPHYLAXIS  OF  AND  J. MM  UNITY  FROM  POLIO- 
MYELITIS    236 

Individual  Prophylaxis,  252;  Prophylaxis  for  the  Physician,  259. 

CHAPTER  XL  TREATMENT  OF  PREPARALYTIC  STAGE  AND 
PROGRESSIVE  ASCENDING  OR  DESCENDING 
PARALYSIS  \\'mi  IMPENDING  PARALYSIS  OF 

RESPIRATION 260 

General  Treatment,  263 :  Medication,  267. 

CHAPTER  XI 1.     I  IYDUOTHERAPY  IN   INFANTILE  PARALYSIS  ....   280 
Warm-water  Bath  for  Paralytic  Limb  at  Bedtime,  283. 

CHAPTER  XIII.     ELECTROTHERAPY   285 

High-frequency  Current  During  Acute  Stage,  288;  the  Combined 
Galvanic  and  Faradic  Current  in  the  Early  Treatment  of  Paralysis, 
293 ;  Electric  Treatment  of  the  Chronic  Paralytic  and  Atrophic 
Stage,  298;  Reaction  of  Degeneration,  303;  Presence  of  Pain  During 
Electric  Treatments,  305. 

CHAPTER  XIV.      PHYSICAL  THERAPY,   MASSAGE.   AND    PASSIVE 

MOTION  307 

Physical  Therapy,  307;  Massage,  308. 

CHAPTER  XV.    THERAPEUTIC  EXERCISES  PERFORMED  BEFORE  A 

MIRROR 314 

Method  of  Mirror  Treatment,  322;  Breathing  Exercises,  328. 

CHAPTER  XVI.     MECH  ANOTIIERAPY 330 

The  Ankle-joint,  350. 

CHAPTER  XVII.    SURGICAL  TREATMENT  OF  POLIOMYELITIS  ...   351 

Tendon  Lengthening,  352;  Tendon  Shortening,  354;  Muscle  and 
Tendon  Transference,  354;  the  Application  of  Artificial  Tendons 
and  Ligaments,  358 ;  Arthrodesis,  or  Joint  Stiffening,  361 ;  Nerve 
Transference  and  Xerve  Grafting,  364. 

IN DEN  367 


LIST  OF  ILLUSTRATIONS. 


FIG.  PAGE 

1.  Map  of  Wisconsin  Face  2 

2.  Distribution  of  infantile  paralysis  in  1908,  in  the  city  of  Ean  Claire. 

\\  is F~ace  4 

3.  Map    (diagrammatic)    of   United    States    5 

4.  Prevalence  of  cases  in  United  States   6 

5.  Experimental  paralysis  of  all   four  extremities  in   monkey.      (After 

Romer)    35 

6.  Experimental  facial  paralysis  (right)  in  monkey.     (After  Romer) . .  36 

7.  Experimental  right  oculomotor  paralysis  in  monkey.     (After  Romer  ).  37 
Experimental  paralysis  of  right  hind  leg  in  monkey.     (After  Romer).  38 

9.  Experimental  facial  paralysis  (right)  in  monkey.     (After  Romer}..  39 

10.  Experimental  paralysis,   facial  and  hypoglossal,   in  monkey.      (After 

Romer) 40 

11.  The   stable-fly;   barn-fly;   rain-fly    (Stomo.vys  calcitrans)    43 

12.  Bedbug  (Cime.r  lectularius)  ;  egg  and  newly  hatched  larva 51 

13.  Bedbug  (Cimejr  lectularius)  ;    adult  female   52 

14.  Alimentary  canal  and  mouth  parts  of  bedbug  (Cimex  lectularius}...  53 

15.  Infantile  paralysis  in  Massachusetts.     (Lorett  and  Richardson)   76 

16.  Acute  poliomyelitis  of  spinal   cord    (human).     Meningeal  and  peri- 

vascular  infiltration.     (Skoog)   Face  86 

17.  Inflammatory  process  extending  throughout  anterior  horn Face  86 

18.  Electrocardiogram    of    arrhythmia    regularly    seen    in    fatal    cases. 

(Peabody,  Draper,  and  Dochez}    Face  86 

19.  Diffuse  areas  of  hemorrhage  in  the  gray  matter  of  the  cord.     (After 

Peabody,  Draper,  and  Dochez}    Face  86 

20.  First  sacral  segment,  showing  infiltration  of  mononuclear  cells  in  the 

pia  mater  at  anterior  fissure  and  in  the  sheath  of  vessels  .  .Face  86 

21.  Showing  the   intense   infiltration   of   mononuclear   cells  around  the 

anterior  spinal  vessels,  both  in  its  walls  and  in  the  adjacent  gray 

matter  of  the  anterior  horn  Face  86 

22.  First  sacral  segment,  showing  the  intense  infiltration  of  mononuclear 

cells    in    the    pia    mater    Face  86 

23.  Spinal    cord    with    acute    spinal    paralysis    forty-three    years    after 

beginning  of  disease 88 

24.  Blood  extravasation  into  the  motor  area  of  the  spinal  cord  89 

25.  General  view  of  human  cord  (cervical  level)  in  poliomyelitis  90 

26.  Perivascular  small  round-cell  infiltration   91 

27.  Round-celled  infiltration  and  hemorrhagic  areas  92 

28.  Actual  shortening  of  left  leg.     Note  epiphysial  line Face  100 

29.  Drop-foot    and    shortening.      Compare    with    X-ray    of    club-foot 

(Fig.  3n Face  100 

(ix) 


x  LIST  OF  ILLUSTRATION'S. 

FIG.  PAGE 

30.  Paralysis  of  right  leg,  with  shortening,  at  9,  from  infantile  paralysis 

at  4  years  of  age Face  100 

31.  X-ray  of  foot,  showing  bony  deformity   Face  100 

32.  Club-foot  from  infantile  paralysis   102 

33.  Aunt,  18  years  of  age,  poliomyelitis  at  9  years  of  age,  and  niece,  a 

normal  child,  3  years  of  age ;  paralysis,  atrophy,  contractures, 

and  trophic  non-development.     (Dr.  Louis  .-Igcr)    110 

34.  Posterior  view  of  Fig.  33   Ill 

35.  Paralysis  of   facial   nerve    129 

36.  Typical  case  of  poliomyelitis,   lateral  view    132 

37.  Same  as  Fig.  36,  anterior  view   133 

38.  Same  as  Fig.  36,  posterior  view  133 

39.  Poliomyelitis     involving     the     neck.       Note     forward     "head-drop." 

(Sheffield)    137 

40.  Paralysis  of  right  leg,  left  arm,  and  face,  with  pain  and  hyperesthesia  139 

41.  Paralysis  of  muscles  of  left  abdominal  wall,  with  hernia 140 

42.  Most  common  type  of  spinal  form  of  poliomyelitis.     Paralysis,  atro- 

phy, and  shortening  of  one  lower  extremity  143 

43.  Spinal  type.     Actual  shortening  one  and  one-half  inches  in  two  years.    144 

44.  Paralysis,    atrophy,    scoliosis,    and    rotation    following    acute    polio- 

myelitis        145 

45.  Posterior  view  of  Fig.  44 145 

46.  Spinal  type.     Paralysis  of  serrati,  latissimus  dorsi,  and  erectors  of 

spine ;  atrophy,  scoliosis.    Anterior  surface 153 

47.  Same  as  Fig.  46.    Posterior  surface  153 

48.  Atrophy  and  lordosis  with  rotation  following  upper  segment  paralysis. 

with  paralysis  of  serrati.  latissimus  dorsi.  and  erector  spinse. 

Anterior  view   157 

49.  Same  as  Fig.  48.     Posterior  view  157 

50.  51.  Oculomotor  type.     Strabismus    15S.  15° 

52.  Acute  bulbar  type.     Left  facial   162 

53.  Acute  bulbar  type.    Right  facial   li  .3 

54.  Congenital  spastic  paralysis  166 

55.  Same  case  as  Fig.  54  lt>7 

56.  Bilateral  drop-foot  168 

57.  Shortening 169 

58.  Scoliosis,  drop-foot,  and  shortening  171 

59.  Posterior  view  of  Fig.  58 171 

60.  Profound  stupor,  paralysis  of  left  arm,  retraction  of  neck.     (After 

Peabody,  Draper,  and  Doches}   1SS 

61.  62.  Intercostal    paralysis    of    abdomen,    and    retraction    of    thorax. 

(After  Peabody,  Draper,  and  Doches)   IS" 

63.  Familial  type.    Patient  one  of  three  brothers  equally  afflicted 197 

64.  Facial  paralysis  in  23  months'  infant  referred  as  a  case  of  infantile 

paralysis 203 

65.  Acute  bulbar  type,  with  paralysis  of  facial  nerve  203 


LIST  OF  ILLUSTRATIONS. 


XI 


:1G.  PAGE 

66.  Scoliosis  following  acute  poliomyelitis   227 

67.  Scoliosis  following  poliomyelitis   227 

68.  Paralysis,  contractures,  and  deformity  eighteen  months  after  attack 

of  poliomyelitis,  in  a  girl  11  years  of  age  230 

69.  Posterior  view  of  Fig.  68   231 

70.  Lateral  view  of  Fig.  68  231 

71.  Total  regressive  paralysis  of  all  four  extremities,  with  atrophy  and 

normal  function.     No  early  treatment  286 

72.  Total    regressive   paralysis   of   all    four   extremities,   with   treatment 

initiated  during  acute  stage   287 

73.  74.  Infantile  paralysis 289,  291 

75.  Same  as  Fig.  74,  posterior  view   291 

76.  Same  as  Fig.  74,  one  year  later   292 

77.  Same  as  Fig.  76,  posterior  view  292 

78.  No  treatment  for  fourteen  years  with  flail  arm  and  total  disability  . .  295 

79.  Perfect  result  following  treatment  297 

80.  Acute  ascending  paralysis,  with  paralysis  of  diaphragm  299 

81.  Same  case  as  Fig.  80.     Recovery  299 

82.  Success  with  massage  and  electricity   302 

83.  Infantile  paralysis  at  \Yz  years  of  age;  at  16  great  improvement  after 

six  months'  constant  treatment  305 

84.  Massage   and   resistance   exercises    309 

85.  Total  paralysis  of  both  legs    311 

86.  Same  as  Fig.  85   311 

87.  In  mirror  X  is  seen   foot  placed  at  right  angle  to  be  brought  up 

through  arc  of  30  degrees.     In  mirror  Z  observe  instructor's 
hands  under  leg  and   foot    .- 315 

88.  Normal  standing  position,  showing  deflection  of  spine  before  mental 

and  muscle  effort  for  correction   316 

89.  Deflection  corrected.    Maximum  muscle  effort  at  point  of  pencil  ....  317 

90.  Plumb-line  test  to  demonstrate  muscle  contraction   318 

91.  Plumb-line  test  to  demonstrate  muscle  control   319 

92.  Muscle  effort  and  muscle  balance   (erector  spinae)   acquired  by  cor- 

rective exercises  for  lateral  curvature  320 

93.  94.  Therapeutic  exercises  before  a  mirror.    Individual  instruction. 321.  323 

95.  Suspension  correction  for  lateral  curvature  325 

96.  Able  to  walk  with  almost  normal  gait  after  one  year's  treatment  . . .  327 

97.  Night  support  for  foot  and  instep   330 

98.  Private  patient  at  the  hospital  with  infantile  paralysis  involving  mus- 

cles of  both  legs  and  spine  331 

99.  Same  as  Fig.  98,  anterior  view   331 

100.  Same  as  Fig.  98,  posterior  view   332 

101.  Neglected  case  of  paralysis  of  both  lower  extremities  with  involve- 

ment of  muscles  of  eye  (abducens  and  left  oblique)   333 

T02.  Brace ;  motion  confined  to  one  axis 333 

103.  Hyperextension  of  knees   334 


xii  LIST  OF  ILLUSTRATIONS. 

FIG.  PAGE 

104.  Same  as  Fig.  103.  with  hyperextensioh  of  knees  corrected,  anterior 

view    335 

105.  Same  as  Fig.  104,  lateral  view  335 

Kh.   Paraplegia,  with  slight  spontaneous  improvement  of  muscles  of  left 

leg    336 

107.  Same  as  Fig.  106,  after  three  months'  treatment  337 

108.  Same  as  Fig.  107   337 

109.  Old  operation  and  brace  treatment  33S 

110.  P.  S.,  scoliosis  following  acute  poliomyelitis,  erect   339 

111.  Same  as  Fig.  110,  stooping  340 

112.  X-ray  of  spine  of  P.  S Face  340 

1.13.  M.  K.,  scoliosis  following  acute  poliomyelitis,  erect   341 

1 14.  Same  as  Fig.  1 13,  stooping  342 

115.  X-ray  of  spine  of  M.  K Face  342 

1 1<>.  Extreme  kyphosis  following  acute  poliomyelitis  343 

117,  118,  119.  Same  as  Fig.  116 '. 343,  344 

120.  Scoliosis  345 

121.  Scoliosis,  with  incorrect  application  of  jacket  346 

122.  Scoliosis,  with  correct  application  of  jacket  346 

123.  Hammock  suspension  sling  for  forcible  overcorrection  of   scoliosis 

while  applying  plaster  jacket  347 

124.  Plaster  jacket  for  scoliosis  applied  in  attitude  of  overcorrection  and 

fenestrated  for  development  of  atrophied  muscle  34S 

125.  Plaster  jackets  for  scoliosis  applied  in  overcorrection  and  fenestrated 

for  development  of  atrophied  muscle  and  compressed  lung  ....  349 

126.  Old  talipes  with  atrophy.     Reduced  in  one  sitting 353 

127.  Postoperative   clutf-foot    355 

128.  Frauenthal    brace    359 


CHAPTER   I. 

Epidemics  and  Pandemics  of  Infantile 
Paralysis. 


THE  WISCONSIN  EPIDEMIC  OF  INFANTILE 
PARALYSIS  IN  1908.1 

THE  epidemic  of  spinal  paralysis  in  Wisconsin  during 
the  summer  of  1908  began  in  the  vicinity  of  Eau  Claire 
and  spread  out  from  there,  as  Dr.  Chas.  Harper,  Secre- 
tary of  the  State  Board  of  Health,  told  us,  like  circles 
in  water. 

\Yhen  it  became  apparent  the  malady  was  extending 
through  the  State,  the  editor  of  the  State  Medical  Journal 
requested  reports  of  all  cases  sent  in  (to  Dr.  Manning) 
and  inserted  a  blank  in  each  copy  of  the  journal  for  such 
report.  Reports  of  408  cases  were  received,  and  the  un- 
diagnosed  and  unreported  cases  would  probably  bring 
the  number  of  cases  in  "Wisconsin  close  to  the  1000  mark. 

The  map  of  "Wisconsin  shows  the  involved  areas.  One 
hundred  and  sixty-seven  of  the  cases  occurred  in  Eau 
Claire  City  and  County.  In  the  northwest  corner  is  a 
small  group  of  35  cases  which  occurred  during  the  summer 
at  Moose  Lake,  Minn.  From  these  408  cases  I  have 
selected  150  for  clinical  classification.  Here  are  the  brief 
histories  of  2  cases  illustrating  the  mild  and  serious  forms 
of  the  disease: — 


JAn  excerpt  from  the  report  read  at  the  Sixty-third  Annual  Meeting 
<>f  the  Wisconsin  State  Medical  Society,  July  i.  1909.  by  Dr.  Manning,  Secre- 
tary of  the  Eau  Claire  County  Medical  Society.  Reprinted  from  the  Wisconsin 
Medical  Journal  of  April  and  November,  1909. 

(1) 


2  1XFAXTILE    PARALYSIS. 

\Yalter  Y.  H.,  i_>  years;  July  30,  1908;  predisposing  cause, 
overexertion  on  a  hot  day.  lluiTalo  Hill's  circus  in  town;  pain,  vomit- 
ing, epistaxis,  fever,  headache ;  temperature  100°  to  104°  F. ;  no 
rash;  paralysis  of  left  leg  only;  reflexes  lost;  slight  atrophy;  no 
contractions;  is  now,  Nov.  10,  1908,  fat,  strong,  and  well  except 
motor  paralysis  of  left  leg.  (Dr.  D.  B.  Collins.  Madison. ) 

Essie  M.,  10  years,  female,  no  predisposing  cause;  no  other 
cases  in  house,  but  two  in  neighborhood ;  pain  in  neck  and  back ; 
severe  headache;  vomiting;  temperature  99°  to  103°  F. ;  Sept.  16, 
paralysis  of  both  legs,  ascending  involved  arms,  then  trunk;  reflexes 
absent;  death  third  day;  prostrated  from  time  of  onset;  conscious; 
spinal  type;  no  brain  symptoms.  (Dr.  A.  E.  Howies,  Kleva.  > 

CLASSIFICATION  OF  150  CASES  OF  POLIOMYELITIS. 

Month  of  Occurrence. — January,  i;  February,  o; 
March,  o;  April,  o;  May,  3;  June,  4;  July,  19;  August, 
44;  September,  55;  October,  21;  November,  2;  Decem- 
ber, i. 

Age. — Less  than  one  year,  10;  one  to  five  years,  64; 
six  to  fifteen  years,  62;  over  sixteen  years,  14. 

Sex. — Males,  91 ;  females,  59. 

Other  Cases  in  House. — This  inquiry  brought  out  29 
cases  of  direct  exposure  to  infection ;  25  of  the  children 
became  ill  during  the  time  or  immediately  following  a 
case  in  the  same  house.  One  boy  (R.  D.)  slept  in  a  tent 
with  a  boy  who  died  of  it  four  days  later,  the  very  day 
the  boy  (R.  D.)  was  taken  ill.  One  case  had  used  milk 
supplied  from  a  house  where  there  was  a  case.  Dr.  Ouade, 
of  Wausau,  reported  a  case  occurring  in  a  house  in  which 
a  case  had  developed  three  years  before;  Dr.  Cassidy,  <>f 
Durand,  reported  a  case  which  developed  in  a  house  in 
which  a  case  occurred  twenty  years  before.  Seven  cases 
occurring  in  the  families  of  physicians  have  been  reported. 

Symptoms  of  Onset. — Fever.  In  the  95  cases  in  which 
the  temperature  is  given,  84  had  a  temperature  of  100° 


(SHOVING  THE  DISTRIBUTION 
i!  OK  INFANTILE  PARALYSIS 
IN  1908 


Fig.  1. — Map  of  Wisconsin. 


EPIDEMICS    AXD    PANDEMICS.  3 

to  104°  F. ;  3,  to  105° ;  5  are  said  to  have  been  "very  high"  ; 
3,  from  98°  to  99  . 

Pulse.  The  pulse  is  given  only  twelve  times,  as  it 
unfortunately  was  not  called  for  in  the  blank;  when  given 
it  is  high,  ranging  from  100  to  168,  and  in  fatal  cases 
could  be  counted  only  by  the  stethoscope ;  in  one  case  that 
is  making  a  fair  recovery,  a  child  7  years  of  age,  the 
pulse  remained  at  160  for  forty-eight  hours  after  the 
onset,  dropping  to  120  when  the  paralysis  appeared,  when 
it  gradually  dropped  to  78. 

Nervous  symptoms.  Headache  and  backache,  66 
times;  pain  and  tenderness  in  limbs,  22;  convulsions  and 
convulsive  movements,  26;  tremor  and  inco-ordination, 
2:  cervical  and  spinal  rigidity,  25;  opisthotonus,  9;  "stiff 
as  a  log  from  head  to  heels,"  I ;  delirium,  12.  Hyperesthe- 
sia  of  skin  is  often  mentioned. 

Digcstii'c  System. — Vomiting,  62  times,  twice  pro- 
jectile in  character;  gastrointestinal  irritation,  24  times. 

Urinary  Organs. — Retention,  n  times;  suppression 
of  urine,  once;  dysuria,  twice;  paralysis  of  sphincters, 
many  times. 

Shin. — A  rash  is  noted  16  times;  the  writer  has  seen 
a  rash  in  every  case  but  one  seen  in  the  acute  stage. 
Herpes  labialis,  once. 

Distribution  of  Paralysis. — One  lower  extremity,  26; 
both  lower  extremities,  46;  two  lower  and  one  upper,  4; 
both  lower,  one  arm,  and  dyspnea,  2;  both  lowrer  and 
sphincters,  3;  one  arm  and  one  leg,  3;  all  extremities,  6; 
facial  only,  2;  general  paralysis,  12;  deltoid  and  shoulder, 
2 ;  sternomastoid,  6 ;  left  peroneus  and  bladder,  i ;  coma- 
tose for  several  days,  no  paralysis,  2;  paresis  only,  6; 
paralyzed,  no  further  data,  1 1 ;  fatal  cases,  22. 

The  map  of  Eau  Claire  shows  the  neighborhoods  which 
in  succession  were  invaded. 


4  1XI-AXT1LE    PARALYSIS. 

in  the  city  of  Eau  Claire,  in  a  small  area  of  the  ninth 
ward,  there  were  <•)  cases  and  3  deaths  the  last  week  of 
July.  Following  these  cases  a  number  promptly  appeared 
scattered  pretty  well  over  the  town,  hut  each  early  case 
in  a  neighborhood  was  followed  by  several  in  that  imme- 
diate locality. 

On  looking-  back  through  the  death  certificates  on  file 
in  the  office  of  the  Board  of  Health.  1  found  the  death 
reported,  on  May  J«nh  of  that  year,  of  a  girl  aged  7  wh<> 
lived  just  across  the  river  from  these  cases,  and  at  the 
east  approach  of  the  same  bridge.  The  death  certificate 
read:  Cause  of  death,  "measles:  contributing  cause, 
epilepsy."  She  had  been  sick  three  days.  The  family 
said  she  had  never  had  a  fit  before.  The  Norwegian 
physician,  who  was  called  to  the  case  a  very  few  hour- 
before  death  occurred,  admitted  to  me  that  it  was  probably 
an  undiagiiMsed  case  of  poliomyelitis  of  the  fulminating 
type. 

Further  investigation  of  the  death  certificates  showed 
that  a  young  man  of  20  years  had  died  of  convulsions  in 
this  same  neighborhood  on  July  i6th.  lie  was  sick  les< 
than  one  day,  and  no  doctor  had  been  called  to  the  case 
till  death  occurred. 

The  last  distinct  group  of  cases  to  appear  was  in  the 
third  ward.  This  is  the  aristocratic  residence  portion, 
and  is  somewhat  separated  from  the  rest  of  the  town. 

The  first  case  in  this  area  appeared  September  ;th. 
and  heralded  15  cases  and  5  deaths.  Although,  a-  I  said, 
this  is  the  aristocratic  section  of  the  town,  a  wagon  road 
crosses  it  from  the  farming  districts  to  the  east  of  the  city. 
On  this  wagon  road  a  watering  trough  for  stock  was 
placed  and  a  man  of  50  years  of  age  opened  a  small  shop 
nearby,  where  all  of  the  children  ran  for  bonbons.  The 
first  3  cases  were  one-half  block  from  thi<  shop,  three 


Fig.  2.— Distribution  of  infantile  paralysis  in  1908,  in  the  city  of  Eau  Claire,  Wis.,  taken 
from  Dr.  Jacolyn  Manning's  Report  to  the  Wisconsin  State  Medical  Society  at  Madison,  Wis., 
July  1,  1909. 


EPIDEMICS    AXU    PANDEMICS. 


boys  in  three  different  homes,  each  of  which  developed 
a  paralysis,  but  recovered.  One  block  south  on  the  same 
street,  2  brothers  developed  the  disease  on  Wednesday 
and  Thursday  preceding  the  Sabbath  on  which  they  both 
died  within  five  hours.  Called  in  consultation  I  witnessed 
these  2  deaths,  the  termination  in  each  case  due  to  an 
ascending  paralysis.  Fourteen  of  the  15  cases  were  chil- 


V/  HAWAII 
/         " 


^    LEGEND 

•^DISEASE  REPORTABU 

BY  UW.  NOT  REPOSTABLE 

IN  OTHER  STATES. 
( F)- FROM  A  SERIES  BY  FROST 
(EST)-  NUMCR  OF  CASES 

ESTIMATED 
±  -  APPROXIMATE. 


DISTRIBUTION  OF 
INFANTILE  B4RALYSIS 
IN  UNITED  STATES 
IN  1910 


ijj.  .3.  —  Map   (diagrammatic)   of  L'nited  States. 


dren  and  young  adults,  but  the  fifteenth  was  the  man  of 
~<>  who  kept  the  little  shop.  On  October  2ist  he  was 
taken  ill.  and  said  to  a  neighbor  who  found  him  sitting 
over  a  stove,  "I  have  had  backaches  before,  but  never  any- 
thing like  this."  He  developed  a  paralysis  of  both  legs 
and  died  October  26th. 

Twenty  miles  south  of  Eau  Claire  is  the  village  of 
Augusta.  Three  miles  from  Augusta  live  the  Wagner 
family,  consisting  of  father  and  mother  and  6  children. 
Their  farm  is  a  clearing  in  the  woods.  They  grew  corn 


IX1-AXTILE    PARALYSIS. 


and  potatoes,  lived  in  a  one-room  log  house,  and  \Yagner 
\\orked  steadily  clearing  his  little  domain,  exchanging 
firewood  for  groceries  and  clothing.  They  had  no  pump, 
carrying  water  from  the  creek  one-fourth  of  a  mile  away. 
In  the  summer  of  1908  they  took  a  boarder,  an  old  man 
who  was  a  county  charge,  for  whom  they  received  the 
sum  of  $1.50  a  wreek.  A  few  days  after  the  old  man's 


-9000- 
-8000- 
-7000- 

-6000-  % 
< 

-5000-^ 
o 

-4000-5 

B 

-3000-  1 

-2000- 

-1000- 


L 


JL 


•0- 


<      1894-1901      Xi902-<06>    '08'  '10 

Fig.  4. — Prevalence  of  cases  in  United  States. 

arrival  he  was  taken  ill.  Mrs.  Wagner  nursed  him,  but 
a  week  later  her  husband  became  ill  in  the  same  manner; 
and  one  by  one  all  of  the  children.  The  old  man  and  3  of 
the  children  got  well.  The  father  was  left  with  a  paralysis 
of  one  leg  and  3  of  the  children  had  an  arm  or  leg  para- 
lyzed— the  girl  aged  10,  a  boy  4  years  of  age,  and  a  baby. 
In  the  report  a  review  of  the  epidemics  of  acute  polio- 
myelitis in  Norway  and  Sweden,  writh  the  occurrence  of 
many  hundred  cases  during  the  four  summers  of  1903-4- 
5-6,  is  given,  with  a  review  of  the  epidemic  in  and  about 


EPIDEMICS    AXD    PANDEMICS.  7 

the  port  of  New  York,  "our  principal  port  of  entry  from 
Europe/'  and  the  article  concludes:  "It  would  seem  that 
a  highly  contagious  disease  had  journeyed  along  the  main 
highways  of  travel  from  the  Old  \Yorld  to  the  Eastern 
United  States,  and  thence  to  these  sections  of  the  Middle 
AYest,  where  there  is  a  large  percentage  of  Scandinavians 
residing." 

"There  were  about  8700  cases  of  infantile  paralysis 
reported  in  the  United  States  in  1910,  and  if  we  contrast 
that  figure  with  the  years  prior  to  1904,  when  the  average 
yearly  number  was  15  cases  per  year,  we  may  appreciate 
what  an  enormous  increase  has  occurred. 

"When  we  come  to  the  analysis  of  the  figures  for 
1910  we  must  remember  that  they  were  brought  out  by 
a  systematic  and  extended  inquiry  undertaken  by  the 
Massachusetts  State  Board  of  Health,  and  probably  had 
such  an  inquiry  been  possible  in  one  of  the  earlier  years  a 
larger  number  of  cases  would  have  been  discovered  than 
now  stand  as  reported  in  those  years.  Still,  one  cannot 
conceal  the  fact  that  in  1910  there  apparently  occurred  a 
very  much  larger  number  of  cases  than  before  all  over 
the  United  States,  and  that  the  extent  and  distribution  of 
the  disease  in  this  country  in  1910  was  of  a  different 
character  from  that  of  any  previous  year."  (Lovett.) 

COINCIDENTAL  EPIDEMIC  PARALYSIS  IN 
ANIMAL  AND  MAN. 

Epidemiologists  of  the  recent  epidemics  of  poliomye- 
litis in  man  have  not  Overlooked  the  coincidental  paralysis 
and  death  among  domestic  animals,  yet  the  aggregate 
of  such  occurrences  has  not  hitherto,  I  believe,  been  as- 
sembled. 

A  close  relationship  between  paralytic  cases  in  man 
and  animal  during  epidemics  of  poliomyelitis  has  been 


8 


INFANTILE    PARALYSIS. 


observed  in  the  United  States,  and  in  Sweden,  Westphalia, 
England,  and  P>razil. 

ACUTE  PARALYTIC  DISEASE  AND  DEATH  AMONG  DOMESTIC  ANIMALS  OCCURRING 
COINCIDENTLY  WITH  EPIDEMIC  POLIOMYELITIS  IN  MAN.     (MANNI1 


Reported 

by 

Locality 

Year 

Horse 

Sheep 

Dog        Cat 

Hog 

Fowls            Total 

Caverly 

Vermont 

1894         Hor.-e 

Dogs 

Chickens      Many 

Wickmann      Sweden 

1905 

Dogs 

And  other 

animals 

Free 

Dubois,  Pa. 

1907 

Pigs 

Chickens 

Manning 

Wisconsin 

1907-08    Colts 

Sheep 

Cats 

Ducks           Many 

Lovett 

Massachusetts  1911         Horse 

Dog        Cats 

Hens            39  in  all 

Hill 

Minnesota 

1909         Colts 

Three 

Snow 

California 

1910         Colts 

Dog        Cats 

Chickens     Many 

Kelley 

Washington 

1910 

Dog  paralyzed 

week  before  onset  in  child 

Williams 

Wash'n.  D.  C. 

1910 

Chickens      Many 

Bierring 

Iowa 

1910 

Cat 

Hog 

Chickens    ;Many 

King: 

Indiana 

1911          18  animals  (1  cow)  paralyzed  among  102  cases  of  poliomvelitis 

Bane 

Ohio-Ky. 

1911 

Chickens 

Krause 

Westphalia 

1910 

Chickens      Many 

Gregorft 

Cornwall, 

Hopper 

England 

1911         Horse,  one  week  before  onset  of 

paralysis  in  boy 

Carina 

Sao  Paulo, 

Brazil 

1910-11    1000  horses  and 

4000  cattle  dead  with   ' 

'symptoms  of   rabies," 

N.Y.Tribune 

Kansas  & 

coincidental  with  13  cases  of  human  poliomyelitis  at  Sao  Paulo 

Oct.  1.  1912 

Nebraska 

1912 

Horse; 

meningitis,   paralysis,   death,  24,000.     Hostlers    >aid   to 

contra 

ct  disea 

se 

Langhorst 

Illinois 

1912 

Dog 

In  the  State  of  Massachusetts  in  1910,  during  an 
epidemic  of  1000  cases  of  poliomyelitis,  paralysis  among 
horses  and  cattle  included  many  colts,  geldings  and  horses. 
and  also  many  heifers,  cows  and  bulls.  One  veterinarian 
attended  15  cases  of  paraplegia  in  cows  ("\Yentzell. 
Beverly)  of  which  most  died.  Three  other  paralytic  cows 
are  said  to  have  had  twisting  of  the  neck,  circled  to  tin- 
right ;  when  forced  to  walk,  complete  paralysis  of  hind 
quarters.  A  Guernsey  hull  with  complete  paraplegia  was 
killed  six  weeks  later,  when  atrophy  of  gluteal  muscles 
was  noted.  (May.) 

The  following  cases  of  sickness,  paralysis  or  death 
among  small  animals  and  fowls  was  noted  during  the 
same  season:— 

Paralysis  in  Domestic  Animals. — The  table  shows  that  out  of 
186  families  in  which  acute  epidemic  poliomyelitis  occurred.  34  home< 
had  illness,  paralysis  or  death  in  82  animals.  One  hundred  and  ten 


EPIDEMICS    AND    PANDEMICS.  9 

of  the  families  above  mentioned  had  animals ;  therefore,  about  30 
per  cent,  of  no  families  with  animals  had  illness,  paralysis  or  death 
in  their  animals.  (Springfield,  Mass.,  1910.  Sheppard. ) 

DATA  AS  TO  DOMESTIC  ANIMALS. 

Families, 

Xo  animals  of  any  kind  in   76 

Animals  present  in   1 10 


186 

6  homes  had  14  hens  with  sickness. 
6  homes  had  6  cats  with  sickness. 
4  homes  had  4  dogs  with  paralysis. 
4  homes  had  12  hens  with  paralysis. 
2  homes  had  deaths  in  2  dogs. 
6  homes  had  deaths  in  6  cats. 
8  homes  had  deaths  in  42  hen-. 
2  homes  had  deaths  in  2  horses. 
34  homes  had  illness,  paralysis  or  death  in  82  animals. 

At  1'enryn,  Cornwall.  England,  on  May  27,  1911,  a  boy  of  6 
years  of  age  was  taken  acutely  ill ;  he  was  observed  falling  about  the 
house ;  he  went  out  and  again  fell  and  was  carried  home,  and  paral- 
ysis of  all  extremities  followed.  This  was  the  second  of  132  cases 
of  paralysis  in  Cornwall  and  Devon,  the  adjoining  shire,  during  the 
-ame  summer.  One  week  before  the  boy's  illness  a  horse  belonging 
t<>  this  lad's  father  had  aJi  attack  of  what  is  locally  known  as  "poke- 
neck  ;"  it  is  said  to  have  been  paralyzed  in  the  neck  and  forequarters  ; 
it  fell  down  in  the  stable  and  was  unable  to  rise ;  when  taken  out  of 
the  stable  with  assistance  it  again  fell ;  it  was  shot  without  having 
been  seen  by  the  veterinary  surgeon. 

June  8th,  a  lad  of  2^  years  became  ill  with  a  paralysis  of  both 
legs.  The  second  boy's  father  had  been  in  the  house  with  the  first 
ca-e.  (Gregor  &  Hopper,  "Poliomyelitis  in  Cornwall,"  British  Med. 
lour.,  Xov.  4.  1911.) 

Reading  of  this  report  of  coincidental  paralysis  in  man 
and  Imrse,  occurring  in  the  same  homestead  during  a 
considerable  epidemic  of  poliomyelitis,  crystallized  a  be- 
lief that  has  been  constantly  augmented  during  four  years' 


10  INFANTILE    PARALYSIS. 

study  of  this  disease.  The  season  preceding  the  "Wisconsin 
epidemic  of  1908  I  was  asked  to  examine  two  recently 
foaled  colts  on  the  stock  farm  of  Chas.  L.  Allen,  of  Kau 
Claire,  \Yis.  These  colts  were  affected  with  a  spastic 
paralysis,  all  four  legs  sticking  rigidly  forward:  when 
lifted  to  a  foothold  they  could  not  stand.  They  were  tw«> 
of  a  considerable  number  of  blooded  colts  that  were  lost 
that  season.  A  young  riding  horse  also  developed  a  spastic 
gait  and  had  to  be  disposed  of. 

During  the  epidemic  of  1000  cases  in  Minnesota  in 
1909  three  colts  were  seen  by  Dr.  H.  W.  Hill,  epidemi- 
ologist of  the  Minnesota  State  Board  of  Health,  ill  with 
a  disease  ''strongly  analogous  in  clinical  history  and 
symptoms  to  the  disease  in  the  human."  (Hill.  Minn. 
Med.  Jour.,  Sept.  i,  1909.) 

These  colts  were  under  the  care  of  Dr.  C.  S.  Shore,  a 
veterinary  surgeon  of  Lake  City,  Minn.,  who  wrote  of 
them  the  following  excellent  clinical  record: — 

In  my  veterinary  practice  of  the  past  five  or  six  years  I  have 
found  a  disease  appearing  among  one-  or  two-  year-old  colts  that 
shows  a  line  of  symptoms  corresponding  closely  to  anterior  polio- 
myelitis in  children.  I  have  had  from  5  to  10  cases  a  year  during  thi> 
time,  always  occurring  during  the  summer  months,  and  the  majority 
of  them  during  the  month  of  August.  The  affected  colts  are  usually 
found  in  the  pasture  unable  to  stand.  The  owner  will  sometimes 
notice  an  unsteady  gait  for  twenty-four  hours  before  entire  loss  of 
motion  occurs.  At  first  the  colts  have  a  rise  of  temperature  to  104°  ; 
pulse  and  respiration  accelerated ;  animal  sweats  profusely ;  there  is 
some  trouble  noticed  in  swallowing,  especially  water ;  bowels  tending 
toward  constipation ;  more  or  less  tympanites ;  retention  of  urine  for 
a  few  hours  at  least.  Head  drawn  back  so  the  end  of  the  nose  tend- 
to  assume  a  position  somewhat  on  the  line  with  the  neck. 

The  death  loss  is  less  than  10  per  cent.,  but  in  those  that  recover 
the  market  value  is  depreciated,  because  of  faulty  gait  the  animal 
assumes  after  an 'attack  of  the  disease;  there  is  atrophy  and  contrac- 
tion of  certain  muscles  or  certain  groups  of  muscles.  It  seems  that 


EPIDEMICS    AXD    PANDEMICS.  H 

the  flexor  muscles  of  the  legs  especially  are  more  often  affected  than 
the  extensor,  and  in  almost  all  of  the  cases  some  of  these  deformities 
are  likely  to  remain  permanent,  causing  a  flexion  of  the  fetlock.  The 
elevators  of  the  head  are  also  likely  to  become  affected,  causing  the 
head  to  have  a  poky  appearance  as  it  is  carried  out  from  the  body. 

After  one  of  these  attacks  the  colt  will  remain  down  from  one  to 
three  weeks,  and  will  then  continue  to  improve  for  a  year,  but  it  sel- 
dom if  ever  makes  a  complete  recovery.  (  Hulk-tin  Mass.  Board  of 
Health.) 

Dr.  Shore's  interesting"  note  that  the  colts  had  difficulty 
in  swallowing  will  be  referred  to  again  later.  It  is  evident 
these  colts  were  affected  by  the  same  disorder  as  the  horse 
at  renryn,  which  died  after  developing  poke-neck'  and 
paralysis  of  the  forequarters. 

The  State  of  California  had  an  epidemic  of  100  known 
cases  of  poliomyelitis  in  1910.  The  majority  of  these  cases 
occurred  in  San  Joaquin  County,  and  according  to  the 
September,  1910,  Bulletin  of  the  California  State  Board 
of  Health,  "veterinarians  report  a  considerable  number  of 
puzzling  paralyses  of  colts  in  San  Joaquin  County,  where 
the  largest  number  of  cases  have  occurred  so  far." 

Historical  Cattle  Plagues. — At  Echternach  in  the 
Luxembourg  there  is  an  annual  dance  through  the  church, 
of  pilgrims,  headed  by  the  clergy,  to  the  shrine  of  St. 
\Yillibrod.  The  pilgrimage  is  done  by  way  of  vows  for 
the  cure  of  nervous  diseases.  The  local  legend  asserts 
that  the  ceremony  had  its  origin  in  a  cattle  plague  which 
began  in  the  eighth  century,  which  ceased  through  an 
invocation  to  the  saint.  The  dance  is  headed  by  the  clergy 
and  proceeds  to  a  traditional  tune  from  the  banks  of  the 
Sure  to  the  church,  up  sixty-two  steps,  along  the  north 
aisle,  around  the  altar  with  the  sun,  and  down  the  south 
aisle.  Tt  is  curious  that  until  the  seventeenth  century  only 
men  took  part  in  it.  ("Medieval  Stage,"  E.  K.  Chambers, 
T()ii,  vol.  i,  page  163.) 


12  1XFAXTJLF.    PARALYSIS. 

A  knowledge  of  this  plague,  simultaneously  affecting 
animals  and  man  with  an  acute  nervous  disease,  reappear- 
ing at  irregular  intervals  through  the  ages,  and  ceasing 
i  ?  i  on  an  invocation  to  the  saints  after  all  the  susceptibles 
had  been  killed  or  crippled  and  an  immunity  established 
for  the  rest  of  the  inhabitants,  sheds  a  flood  of  light  on  the 
so-called  miracle  cures  of  the  middle  ages  and  today.  A 
thousand  pairs  of  crutches  might  well  adorn  the  walls  of  a 
church  which  could  cure  (  ? )  paralysis  of  the  legs,  but  it 
is  to  be  feared  the  cure  was  inoperative  where  the  paralysis 
was  not  regressive  in  type. 

Pigs  and  Chickens. — The  reports  of  paralyzed  fowl.^ 
from  districts  where  poliomyelitis  exists  are  common,  and 
call  to  my  mind  a  number  of  similarly  affected  hens  I  saw 
some  years  ago  on  the  John  Seymour  ranch  in  Allen 
County,  Kansas.  The  housewife  reported  the  death  of 
a  hundred  hens  from  an  epidemic  disease,  and  called  my 
attention  to  one  of  those  remaining  which  crouched  on 
the  ground,  and  when  disturbed  fluttered  a  short  distance, 
dragging  its  feet.  Other  fowls  were  unable  to  use  one 
wing;  many  chickens  whirled  wildly  about  until  they  fell 
dead.  The  epidemic  was  clearly  an  acute  nervous  dis- 
order, producing  ataxic  and  paralytic  types. 

Examination  of  Paralyzed  Chickens. —  (a)  Dr.  Charles  L.  Dana 
examined  one  of  the  fowls  paralyzed  during  the  Vermont  epidemic  of 
1894,  and  found,  "an  acute  poliomyelitis  of  the  lumbar  portion  of 
the  cord;  no  meningitis;  bacteriological  examination  negative." 
(Caverly,  loc.  cit.) 

(b)  Dr.  F.  A.  Ely  examined  a  paralyzed  chicken  with  a  most 
suggestive  history  from  a  Boone  County,  Iowa,  farm.  The  chicken 
had  an  acute  illness  not  exceeding  three  days  in  duration,  and  one 
wing  and  both  legs  were  paralyzed.  During  the  summer  many  of  the 
chickens  on  this  farm  became  ill  and  disabled,  and  as  soon  as  this 
was  noticed  the  farmer  would  snap  off  their  heads  and  throw  the 
chickens  into  the  hog-yard.  Some  time  later  a  large  hog  developed  a 


EPIDEMICS    AND    PANDEMICS.  13 

typical  paralysis  of  both  hind  legs,  so  that  the  animal  wore  the  skin 
<>tf  his  knees  as  he  dragged  himself  ahout.  In  October.  1910.  Dr.  Kly 
saw  in  consultation  a  child  with  acute  poliomyelitis  on  this  farm ;  at 
the  same  time  of  Dr.  Ely's  visit,  another  case  of  paralysis  was  ob- 
served in  a  chicken  which  was  taken  to  Des  Moines  for  examination. 

Dr.  A.  R.  Robertson,  pathologist  at  Drake  University  Medical 
School,  reported:  "Examination  of  fowl  paralyzed  after  three  days' 
acute  illness  (one  wing,  both  legs).  Upon  exposure  of  the  spinal 
cord,  a  distinct  area  of  softened  cord,  one  inch  in  length,  of  the  lower 
dorsal  and  upper  lumbar  regions  was  observed.  Histological  sec- 
tions from  the  affected  areas  revealed  numerous  small  hemorrhages 
in  the  anterior  cornua.  and  distinct  collections  of  cells  in  perivascular 
and  perilymph  channels,  and  tissue  spaces  of  the  anterior  horns.  The 
histological  picture  was  that  of  acute  poliomyelitis  in  man."  (  Bier- 
ring.  "Acute  Poliomyelitis  in  Iowa  in  1910-1911,"  Interstate  Med. 
Jour.,  Jan.,  1912.) 

At  1'ella.  Marion  County.  Iowa,  one  hundred  and  fifty  miles  dis- 
tant from  the  Boone  County  case,  a  similar  association  between  a 
paralytic  disease  in  chickens  and  cases  of  acute  poliomyelitis  was 
noted.  A  number  of  these  chickens  were  obtained.  Three  of  them 
were  kept  for  two.  three,  and  four  weeks,  until  the  paralysis  and  a 
certain  degree  of  muscular  atrophy  were  established,  and  then  ex- 
amined, with  confirmatory  results.  (Bierring.  loc.  cit.) 

In  September,  1911,  5  cases  of  acute  poliomyelitis  in  Calhoun 
County.  Iowa.  3  of  which  proved  fatal  in  the  first  forty-eight  hours, 
occurred  on  four  different  farms.  On  the  farm  of  each  of  4  of  the 
cases  a  history  of  paralytic  disease  in  lower  animals  was  obtained. 
In  2  instances  chickens  were  affected;  kittens  at  one  farm,  pigs  at 
another.  (Bierring,  loc.  cit.) 

Tlic  Dog. — The  coincidental  paralysis  of  the  dog  and 
human  poliomyelitis  has  been  reported  from  Sweden, 
Vermont.  Massachusetts.  Illinois,  California,  and  the  State 
<>f  Washington.  Kelly,  of  the  State  of  Washington,  re- 
ported that  one  family  had  I  dog  paralyzed  for  two  days 
one  week  before  onset  in  child  (1910).  Langhorst,  of 
Illinois,  reported  2  cases  of  acute  poliomyelitis  succeeding 
paralysis  in  a  dog  with  which  patient  associated.  This 


14  1XFAXTILE    PARALYSIS. 

report  is  given  in  full  under  "Transmission  of  Acute  Polio- 
myelitis through  the  Dog"  in  Chapter  II  of  this  volume. 

The  State  of  Massachusetts  had  an  epidemic  of  923 
cases  of  poliomyelitis  in  1909  and  a  second  epidemic  of 
845  cases  in  1910.  The  summer  of  1910  the  following 
cases  of  paralysis  in  dogs  were  collected  by  the  investi- 
gator employed  by  the  State  Board  of  Health:— 

PARALYSIS  IN  MASSACHUSETTS  DOGS,  1910.     (MAY.) 

Declham.  French  bulldog,  paraplegia  gradually  working  for- 
ward, death. 

Xcwtonville.  French  bulldog,  paraplegia.  Recovered  in  three 
days. 

Amesbury.  Twelve-year-old  housedog.  Complete  paralysis, 
posterior  to  lumbar  region,  sudden  and  continuing. 

Boston.     Nine-year-old  housedog,  paraplegia. 

Boston.  Wadsworth.  Three  dogs  of  different  breeds  and  ages  ; 
all  had  same  symptoms :  ascending  paralysis  of  all  four  legs,  coma 
and  death.  Head  twisted  to  right.  Two  lived  for  twelve  days.  The 
puppy  lived  three  days. 

Boston.  Cocker  spaniel.  October  nth,  complete  paraplegia; 
Dec.  5th,  dog  able  to  walk  and  improving. 

Salem.  Several  cases  of  paraplegia  in  dogs,  accompanied  by 
vomiting ;  all  fatal. 

Reading.  Six  cocker  spaniels  from  4  to  /  years  of  age.  Para- 
plegia, some  very  sensitive  to  touch.  Recovery. 

Boston.  May.  Spaniel.  Slight  paraplegia  developing  complete 
paralysis  of  hind  legs,  bowels  and  bladder  in  August,  1905.  Paral- 
ysis and  atrophy  present  in  1910. 

Sheep. — "In  England  paralysis  is  epidemic  among 
sheep  in  the  early  autumn  each  year."  ("Torment  of 
Flies,"  Shipley,  Christ  College,  Cambridge.)  It  is  well 
known  that  Sir  Walter  Scott  was  afflicted  with  a  short  and 
withered  leg.  He  had  an  acute  illness  when  he  was  a 
small  lad  which  left  him  unable  to  walk,  and  he  was  given 
in  charge  of  an  old  shepherd  of  whom  he  was  very  fond. 


EPIDEMICS   AND    PANDEMICS.  15 

This  shepherd  took  the  boy  out  in  his  plaiddie  to  the  fresh 
air  of  the  sunny  hillsides,  and  health  returned  to  him,  but 
he  was  left  with  a  paralysis  of  one  leg. 

In  the  fine  study  of  the  life  of  the  English  shepherds 
of  today,  W.  H.  Hudson  relates  the  story  of  an  ataxic 
sheep,  told  by  the  shepherd,  Caleb  Bawcome,  who  was 
himself  the  victim  of  poliomyelitis.  The  description  of 
man  and  sheep  is  as  follows: — 

"Caleb,  a  shepherd  of  the  clowns.  A  very  tall,  big-boned,  round 
shouldered  man,  uncouth  to  grotesqueness,  who  walked  painfully 
with  the  aid  of  a  stick,  dragging  his  shrunken  and  shortened  bad  leg. 
He  told  me  that  when  he  were  a  young  man  he  was 
once  putting  the  sheep  in  the  fold,  and  there  was  one  that  was  giddy, 
a  young  ewe.  She  was  always  turning  round,  and  round,  and  round. 
And  when  she  got  to  the  gate  she  wouldn't  go  in,  but  kept  a'turning 
and  a'turning  'till  at  last  he  got  angry  and,  lifting  his  crook,  gave  her 
a  crack  on  the  head."  He  tells  of  other  giddy  sheep,  "giddy  because 
they  had  a  maggot  on  the  brain,  or  some  other  trouble  I  couldn't  find 
out."  He  also  tells  of  an  unlucky  farmer  in  those  parts  whose  sheep 
fell  sick  and  died  in  numbers,  year  after  year,  bringing  him  down 
to  the  brink  of  ruin.  ("A  Shepherd's  Life,"  W.  H.  Hudson,  pages 
52,  127,  and  352.) 

Here,  then,  is  a  record  of  an  epidemic  sheep  plague 
occurring  annually;  a  very  good  description  of  an  indi- 
vidual case  of  the  ataxic  type  occurring  in  a  young  ewe; 
the  shepherd  presenting  the  typical  flaccid  paralytic  type; 
and  our  knowledge  of  Walter  Scott,  the  child  of  aristo- 
cratic parents,  contracting  the  acute  disease  coincidently 
with  association  with  a  shepherd. 


16 


1XFAXTILE    PARALYSIS. 


A    TAl'.LE    OK    EPIDEMICS    AND    PANDEMICS    OK    ACITE 

POLIOMYELITIS.    COMPILED  KROM  MAXY  SOURCES 

BY  DR.  JACOLYX  V.  V.  MAXXIXG. 

Ytur.     Locality.  Cases.     Deaths.  Reported  by 

1.S41.   Louisiana 11        ....       Colmer,  Am.  Jour.  Med.  Sc..  Tan., 

1843. 

ISfiS.   Norway 14       ....        Bull. 

1S75.  Philadelphia  (in  4  years)   ...       86       Sinkler,    Bost.   Med.   Sury..    Nov. 

23,  1898. 
issl.  I'mea,  Sweden   13      .....       Bergenholz-Medin.     Intrn.     Med. 

Con. 

ISSo.  S.  Koy,  Germany  13  4      Cordier,  Lyon  med.,  1888. 

ISSo.  Mandel,   X<>r\vay   9       ....       Oxholm-Leegard,   Netir.  Centrb.. 

1890. 

1887.  Stockholm.    Sweden    43  3       Medin.  Xord.  Med.  Ark..  1896. 

1S«;3.   Boston  26       Putnam,  Boston  Med.  Jour.,  1893. 

is0.}.  St.  Girons,  Krance 9       ....       Andre,  Compt.  de  med.  Bordeaux. 

IS' 4.   X.  Adams,  Mass 10       Brackett.    Tr.    Am.    Orth. 

xi,  132. 

1894.  Rutland,  Vermont  132  18      Caverly,  N.  Y.  Med.  Record,  1894. 

!S"5.  Spertoli,  Italy   7       ....       Pericinni,   La   Sperimental.    1895. 

1895.  Genoa   ." 6       ....       Bucelli,  Policlinico,  1895. 

1895.  Stockholm,   Sweden    20       ....       Medin.  Xord.  Med.  Ark.,  1896. 

1896.  Much  Haden,  England 7  1       Pasteur,  Tr.  Clin.  Soc.,  1897. 

1896.  Port  Lincoln,  Australia 18       \ltman,  Austr.  Med.  Gaz.,   1897. 

1896.  Cherryfield,   Maine    7  1       Taylor,  Phil.  Med.  Jour.,  1898. 

lS')d.  Greene  Co.,  Ala.   15      ....       Bondurant,  Phil.  Med.  News,  1901. 

1897.  London    11       ....       Buzzard,  Lancet,  1898. 

1897.  Kiel,  Germany.  Baltic  Sea  . .         4       ....       Pleuss,  Inaug.  Diss.,  Kiel,  1898. 

1897.  Xew  York  City   12       ....       H.  L.  Taylor,  N.  Y.  Med.  Jour., 

1897. 

IN'W.  Lc  Grand,  Cal 4       ....       Xewmark,  Med.  Xews,  Phil.,  1899. 

IS'*.   Koyersford,  Pa 22       Jour.  Xerv.  and  Ment.  Dis.,  1899. 

1SW.  Vienna 208       ....       Zappert.  Tahrh.  f.  Kinderheil.,  111. 

1898.  Frankfort  on   Main    9       ....       Auerbach,  Xeur.  CentralbL  1900. 

1899.  Stockholm.  Sweden 54  3       Wickmann,   Heine   Med.   Krank.. 

1907. 

1899.  Bratsburg,  Xorway  54  2      Leegard,    Xorsk    Mag.    f.    T 

1901. 

1899.  Poughkeepsie,  X.  Y 37  1       H.  D.  Chapin.  Arch.   Pod..   1900. 

1900.  Gloucestershire,  Mass 52       ....       Painter.  Trans.  Am.  Orth. 

1902. 

1901.  San   Krancisco,  Cal 55       ....       Woods,  Occidental  Med.  J.,  xvii. 

77. 
ln(>3.  Gotteburg,  Sweden   20  1       YVickmann.   Urine   Med.   Krank.. 

1907. 
1903.  Xorway    18  6      Harbitz,   Jour.    Am.    Med.    Asso. 

1903.  Parma,  Italy   26       ....       Lorenzelli,  La  Pediatria.  1904. 

1905.  Queanbergen,  N.  S.  W 6       ....       Blackball,  Austr.  Med.  Gaz.,  l'*>4. 

1905.  Sydney,  Australia   25       Litchfield. 

1905.  Stanmore,  Australia  34       Wade. 

I'JO.r   I'.risbane,   Queensland    108  4      Ham,  Austr.  Med.  Gaz. 

1904.  Ilvalen,   XTorway    41        ....        Xannsted,    Xorsk    Mag.    f.    l.ae-.. 

1906 

1904.  Aaf Jordan.   Xorway   20  6       Platon,  Tidssk.  f.  d.  Xorsk. 

1904.  Trondheim.  Xorwav  437          67       C.iersvold.   Xorsk  Mag.    f.    I 


EPIDEMICS    AND    PANDEMICS.  17 

A    TABLE    OF   EPIDEMICS    AND    PANDEMICS    (Continued). 

Year.     Locality.  Cases.     Deaths.  Reported  by 

1904.  Sweden    1031  Wickmann,  Tidssk.   f.   d.  Norsk, 

1906. 

1905.  Norway 952        111       Harbitz,    Jr.    Am.    Med.    Asso., 

Sept.  7,  1912. 

1906.  Norway 466          50      Harbitz,  ibid. 

1907.  Norway  204         30      Harbitz,  ibid. 

1905.  St.  Louis,  Mo Fry. 

1905.  Central    Illinois    8       Norbury. 

1906.  (During  the  year   1906,  curiously   free   from   reports  of  poliomyelitis  in  the 

city  of  New  York,  there  was  said  to  have  been  a  serious  epidemic  of 
cerebrospinal  meningitis.  Contrary  to  the  history  of  the  spread  of 
epidemics  of  all  ages,  the  epidemic  of  3000  cases  of  poliomyelitis  in  the 
year  1907  is  supposed  to  have  appeared  like  a  bolt  from  the  blue.) 


1907.     FIRST  AMERICAN  PANDEMIC. 
Y«ar.     Locality.  Cases.     Deaths.  Reported  by 

1907.  New  York  City   2500  ....  New  York  Committee. 

19(17.  Schenectady 29  ....  Clow,  Alb.  Med.  Jour.,  1908. 

1907.  Oil  City,  Lehigh,  Dubois  and 

Ridgway,  Pa 209  ....  Urey  and  Terriberry. 

1907.  Massachusetts  234  Lovett,  Mass.  State  Bui. 

1907.  Live   Oak,   Florida    16  ....  Efird,  Tr.  Flor.  State  Asso.,  1908. 

1907.  Oceana  Co.,  Mich 20 

1907.  Trempeauleau  Co.,  Wis 22  ....  H.  A.  Jegi,  Tr.  T.  P.  C.  Co.  Med. 

Soc. 


1908.     SECOND  AMERICAN  PANDEMIC. 
Year.    Locality.  Cases.    Deaths.  Reported  by 

1908.  Massachusetts  136       Lovett,  Mass.  State  Bui. 

1908.  Clearfield,  Pa 14       ....       Mills. 

1908.  Salem,   Va 25       ....       Wiley  and  Darden. 

1908.  Florida  16       ....       Frost. 

1908.  Flint,  Mich 30       ....       Manwaring,  of  Flint,  Mich. 

190S.  Wisconsin  State  reported  ...     408 

(est.)  1000  ....  Manning,  J.  V.  V.,  Secretary  Earn 
Claire  Co.  Med  Society,  Wis. 
Jour.  Med.,  April  and  No- 
vember, 1909. 

1'x IS.  Minnesota 150       A.     S.     Hamilton,     Neur.     Dept. 

Univ.  of  Minnesota. 

1908.  Whitmore,   Iowa    9       A.  S.  Hamilton,  ibid. 

1008.  Missouri    Frost,  Public  Health  Bui.,  44. 

1908.  Victoria,  Australia    155  7      Stephens,  Inter.  Co.  Med.  J.,  1908. 


18 


INFANTILE    PARALYSIS. 


A    TABLE   OF    EPIDEMICS    AND    PANDEMICS    (Continued). 
1908  AND  1909.     FIRST  EUROPEAN  PANDEMIC. 

Year.     Locality.  Cases.     Deaths.  Reported  by 

1908.  Russia    (a  village  of  500  in- 
habitants)          49       ....       Schwarz.     St.     Petersburg     med. 

Woch.,  Jan.,  1909. 

1908.  Germany  1000 

1909.  Westphalia  100  . .       Krause,     Deutsch.    med.    Woch.. 

1909. 
1909.  Rhenish  Westphalia    500       ....       Rekseh,  Med.  din.,  1909. 

1908.  Essex,  England    8       ....       Treves,  Brain,  Nov.,  1909. 

1909.  Leyden,  Holland    24       ....       Netter. 

1909.  Spain   9       Netter. 

1909.  France    6       ....       Netter. 

1909.  Zurich,   Switzerland    3       ....       Eichhorst,  Corres.  Bltt,  Basel. 

1909.     THIRD  AMERICAN  PANDEMIC. 
Year.    Locality.  Cases.    Deaths.  Reported  by 

1909.  Massachusetts  923  Lovett,  Mass.  State  Bui. 

1909.  Brooklyn,  N.  Y 150  ....  Le  Grand  Kerr. 

1909.  New  Jersey    (est.)     200       Keppler. 

1909.  Santa  Clara,  Cuba    140  ....  Off.  Sanitary  Bui.  of  Havana. 

1909.  Maryland   a  few  2  Corresp.  Sec.  State  B.  of  H. 

1909.  Minnesota    1100  238  Corresp.  Sec.  State  B.  of  H. 

1909.  Nebraska    999  244  Corresp.  Sec.  State  B.  of  H. 

1909.  Kansas 100  ....  Corresp.  Sec.  State  B.  of  H. 

1909.  California  16  ....  Bulletin  of  the  State  B.  of  H. 

1909.  Oregon    55  11  Corresp.  Sec.  State  B.  of  H. 

1909.  N.  Dakota 75  25  Corresp.  Sec.  State  B.  of  H. 

1909.  Montana   4  Corresp.  Sec.  State  B.  of  H. 

1909.  Indiana    1 14  Corresp.  Sec.  State  B.  of  H. 

1909.  Richland  Center,  Wis 18  ....  Harper,  Sec.  Wis.  State  B.  of  H. 

1909.  Illinois  . ....  Frost. 


1910.     FOURTH  AMERICAN  PANDEMIC  OF  POLIOMYELITIS. 

(The  United  States  Census  Bureau  returns  for  1910  give  1459  deaths  reported 
due  to  infantile  paralysis;  if  the  mortality  is  considered  to  average  10 
per  cent.,  the  estimated  number  of  cases  in  the  United  States  in  1910  would 
reach  the  sum  of  14,590.  Lovett  has  compiled  8700  cases  in  the  United 
States  in  1910.) 


Year.    Locality. 

1910.  Arizona  30 

1910.  California 100 

1910.  Colorado 

1910.  Connecticut    168 

1910.  Delaware    8 

1910.  District  of  Columbia   .......  500 

1910.  Florida    19 

1910.  Idaho  96 

1910.  Illinois  ". 137 

1910.  Indiana    500 

1910.  Iowa 654 

1910.  Kansas 198 

1910.  Kentucky  3 


Cases.     Deaths.  Reported  by 

....  Lovett,  Inf.  Par.  in  U.  S.  in  1910. 

Lovett. 

4  Corresp.  Sec.  State  B.  of  H. 
Lovett. 

...  Lovett. 

...  Williams,  T.  A. 

Lovett. 
Frost. 

...  Frost. 
Lovett. 

157  Bierring.  W. 
Lovett. 

...  Batte,  Dr.  John,  Cincinnati. 


EPIDEMICS    AND    PANDEMICS. 


19 


A  TABLE    OF   EPIDEMICS   AND  PANDEMICS  (Continued). 


Year.    Locality. 


1910.  Louisiana    50 

1910.  Maryland    (est.)  300 

1910.  Massachusetts   ". . .  843 

1910.  Michigan,  Hillside  72 

1910.  Minnesota    1000 

1910.  Montana    (est.)  170 

1910.  Nebraska    144 

1910.  Nevada    9 

1910.  New  Hampshire   (est.)  210 

1910.  New  York  reported   •.  225 

(est.)  460-500 

1910.  N.  Dakota (est.)  150 

1910.  Ohio 50 

1910.  Oklahoma 20 

1910.  Oregon    112 

1910.  Pennsylvania   1006 

1910.  S.  Carolina 150 

1910.  Rhode   Island    231 

1910.  S.  Dakota 86 

1910.  Utah    (est.)  120 

1910.  Vermont    48 

1910.  Virginia    335 

1910.  Washington   225 

1910.  Wisconsin    (est.)  370 

1910.  Montreal.  Quebec    38 

1910.  Ontario,  Canada 17() 

1910.  British  Columbia  .             ....  75 


Cases.     Deaths.  Reported  by 

Lovett. 
Lovett. 
Lovett. 

12      Green,  Dr.  B.  F.,  of  Hillside. 
Lovett. 
Lovett. 

Corresp.  Sec.  State  B.  of  H. 
Lovett. 
Lovett. 

Frost. 

Frost. 
Lovett. 

Corresp.  Sec.  State  B.  of  H. 
Corresp.  Sec.  State  B.  of  H. 
. . .       Bui.  S.  C.  State  B.  of  H. 
23       Frost. 
Lovett. 
Love.tt. 

Corresp.  Sec.  State  B.  of  H. 
Corresp.  Sec.  State  B.  of  H. 
12      Corresp.  Sec.  State  B.  of  H. 


Colin  Russel,  Montreal. 

Lovett. 

Lovett. 


1910.  Schleswig-Holstein    132       Meyer. 


1911.   (The  United  States  Public  Health  Report  for  April,  1912,  stated  the  returns 
for  1911:    Poliomyelitis,  cases,  1930;    deaths,  440.) 

Year.     Locality.  Cases.     Deaths.  Reported  by 

1911.  New  York  City,  endemic : Manning. 

1911.  Indiana    (to  October  28)    ...     102          17       King. 

1911.  Virginia  Mountains    25       ....       Evan  Evans. 

1911.  Louisiana    20       ....       N.  O.  Times  Democrat. 

1911.  Iowa    68          12      Bierring. 

191 1.  Missouri    

1911.  Arkansas 

1911.  Oklahoma  . 


1911.     EUROPEAN   PANPRMIC. 


Year.  Locality.  Cases.  Deaths. 

1911.  Sweden    .  .  3840  .... 

1911.  Norway    1250        125 

1911.  Denmark    250 


Reported  by 

Kling  and  Petterson. 

Harbitz,  ibid. 

Thomsonn,    Hospitalstidend,    liv, 

1329. 
Gregor  and  Hopper,  and  others. 


1911.  England 150       .. 

1911.  Switzerland,  3  Districts Hagenbach,  Basel. 

1911.  Germany  1000       Slomann,  Copenhagen. 


20  1XTAXTILE    PARALYSIS. 

A  TABLE  OF  EPIDEMICS  AND  PANDEMICS  (Concluded). 

1912.     UNITED  STATES. 
Year.     Locality.  Cases.     Deaths.  Reported  by 

1912.  Massachusetts    (August)    

1912.  New      York      City,     endemic 

(August)    Manning. 

1912.  Buffalo   (August)    300 

1912.  California     (Los     Angeles) 

(August)    

1912.  Norway  117       •    5       Harbitz,   ibid. 

1912.  Sweden    (from  Jan.  to   Aug. 

15)    1458       ....       Kling  and  Petterson. 


CHAPTER   II. 

The  Etiology  or  Exciting  Cause  of  Infantile 
Paralysis. 

FOUR  hypotheses  have  been  advanced  to  explain  the 
nature  of  the  hitherto  unknown  cause  of  infantile  paral- 
ysis:— 

I.  A  chemotoxin. 
II.  Geirsvold's  bacterium,  a  micrococcus. 

III.  Flexner's  filterable,  ultramicroscopic  virus. 

IV.  Dixon's  protozoon. 

I.  Chcuf'0to.rin. — It   was   formerly   held   as   a   theory 
that  acute  poliomyelitis  was  induced  by  the  action  of  a 
chemical  toxin  ingested  in  the  form  of  decomposed  animal 
matter,  and  was,  in  fact,  a  sort  of  ptomaine  poisoning. 
This  theory  has  never  been  supported  by  scientific  investi- 
gation, and  fell  to  the  ground  when  it  was  demonstrated 
that  the  disease  could  be  transmitted  from  one  living  host 
to  another,  with  no  diminution  of  its  toxicity. 

II.  Gcirst -old's    Bacterium    or    Micrococcus. — In    the 
fall    of    K)O5    Geirsvold,    of    Norway,    demonstrated    the 
presence  of  the  same  micro-organism  in  a  whole  series 
of  cases  of  acute  poliomyelitis.     The  organism  was  ob- 
tained three  times  by  direct  examination  and  twelve  times 
by  cultural  methods  from  the  cerebrospinal  fluid.     A  pure 
culture  which  readily  produced  chains  of  four  or  six  ele- 
ments was  grown  in  nutrient  broth.     The  organism  which 
he  described  was  a  bean-shaped  diplo-  or  tetra-  coccus, 
with  certain  cultural  characteristics.     Geirsvold  produced 
paralysis  in  mice,  pigeons,  and  guinea-pigs  by  the  intra- 
venous   injection    of    pure    cultures    of    this    organism. 

(21) 


22  INFANTILE    PARALYSIS. 

Harbitz  and  Scheele  were  unable  to  confirm  the  findings 
of  their  confrere  and  state  in  this  particular  :— 

\Ye  believe  it  at  present  to  be  impossible  to  speak  definitely  on 
the  question  of  the  specificity  of  the  organism  demonstrated  by 
Geirsvold,  the  more  so  as  Geirsvold  himself  makes  certain  reserva- 
tions. (Italics  the  editors'.) 

There  was,  however,  no  lack  of  confirmation  among 
investigators  of  other  countries.  Pasteur.  Fullerton  and 
MacCormac  in  1908  "identified  a  micrococcus  in  the 
spinal  fluid  of  patients  with  symptoms  of  poliomyelitis; 
inoculating  this  fluid  in  the  subdural  space  of  rabbits  in- 
duced an  ascending  motor  paralysis,  with  the  recovery  of 
the  same  micro-organism  from  the  spinal  fluid;  the 
organism  refused  to  grow  on  artificial  media." 

Schultze  found  a  micro-organism  present  in  the  cere- 
brospinal  fluid  during  the  acute  stage  of  an  attack,  and 
also  on  the  thirteenth  day  of  an  attack;  this  organism  was 
a  diplococci,  and  cultivation  was  negative. 

The  bacteriological  work  of  Wickmann,  of  Sweden, 
and  of  many  German  investigators,  including  Krause  and 
Meinicke,  Eichelberg,  Leiner  and  \Yieser,  and  Romer, 
was  negative,  while  Potpeschnigg  states  that  he  found  a 
Gram-positive  diplococci  in  the  cerebrospinal  fluid  of  14 
cases  of  acute  poliomyelitis.  Shidler,  of  Nebraska,  in 
1909,  reported  that  he  made  14  lumbar  punctures,  and 
found  a  sterile  fluid  in  I  case  only,  and  in  that  case  the 
fluid  was  withdrawn  four  weeks  after  the  temperature 
had  subsided;  in  9  cases  a  Gram-positive  coccus  was  ob- 
tained, and  in  3  a  diplococcus;  these  micro-organisms 
were  never  found  to  be  intracellular ;  cultures  were  in- 
conclusive. 

The  results  of  the  bacteriological  research  for  the 
cause  of  poliomyelitis  may  be  summarized  as  follows:— 


ETIOLOGY   OR   CAUSE   OF    INFANTILE   PARALYSIS.         23 

Many  independent  investigators  have  demonstrated 
the  presence  of  a  micro-organism  in  the  cerebrospinal 
fluid  of  cases  in  the  acute  stage  of  the  disease ;  this  organ- 
ism is  of  a  round,  ovoid  or  kidney  outline;  it  is  susceptible 
to  culture  in  a  media  of  nutrient  broth,  which  implies 
anaerobic  environment;  pure  cultures  of  this  organism 
produced  experimental  paralysis  in  animals;  cerebrospinal 
fluid  containing  this  organism  produced  experimental 
ascending  paralysis  in  rabbits,  which  was  capable  of 
transmission  to  a  second  series  of  rabbits. 

It  was  at  this  point  that  the  bacteriologists  seemed  to 
be  hung  up;  their  results  were  not  uniform;  their  pure 
cultures  from  the  cerebrospinal  fluid  became  sterile  in 
from  twelve  to  fourteen  days;  transmission  was  not 
carried  beyond  the  second  series  in  animal  experimenta- 
tion. They  were  agreed  that  they  had  at  least  a  fleeting 
glimpse  of  an  organism,  "not  quite  like"  anything  they 
had  hitherto  studied.  It  is  notable  that  one  man,  Beneke, 
of  Marburg,  whose  work  we  will  have  occasion  to  refer 
to  again  later,  demonstrated  certain  bodies  resembling 
diplococci  in  sections  of  the  pia  and  cord,"  obtained  post 
mortem  from  cases  of  the  acute  disease.  It  was  evident 
that  the  organism,  whatever  it  was,  did  not  belong  to  the 
group  of  readily  cultivated  and  easily  stained  bacteria. 

III.  Fle.rucr's  Filterable  Virus  of  Poliomyelitis. — 
Subsequent  to  the  announcement  by  Flexner  and  Lewis 
that  they  had  successfully  transmitted  epidemic  poliomye- 
litis to  the  rhesus  monkey,  they  published  a  study  on  the 
"Nature  of  the  Virus  of  Epidemic  Poliomyelitis"  in  the 
Journal  of  The  American  Medical  Association,  which  is 
here  given  in  part; — 

"From  the  beginning  our  attention  has  been  directed  toward  the 
solution  of  that  fundamental  question,  the  nature  of  the  virus  re- 
sponsible for  producing  the  disease,  but  the  results  of  our  studies 


24  IXFAXTILE    PARALYSIS. 

were  until  recently  wholly  of  a  negative  nature.  ll'c  failed  utterly  to 
discover  bacteria  whether  in  film  preparation  or  in  cultures  that  could 
account  for  the  disease ;  and  since  among  our  long  series  of  propaga- 
tions of  the  virus  in  monkeys  not  one  animal  showed,  in  the  lesions, 
the  cocci  described  by  some  previous  investigators,  and  we  had  failed 
to  obtain  any  such  bacteria  from  the  human  material  studied  by  us. 
ice  felt  sure  that  they  could  be  excluded  from  consideration.  \Ye 
have,  up  to  this  time,  made  a  very  painstaking  study  of  film  prepara- 
tions and  sections  taken  from  two  specimens  of  human  spinal  cord. 
and  many  specimens  of  the  spinal  cord  and  brain  and  other  viscera 
obtained  from  monkeys,  prepared  and  stained  in  the  most  various 
ways,  but  without  finding  either  bacterial  or  protozoal  parasites  that 
could  account  for  the  infection.  The  readiness  with  which  epidemic 
poliomyelitis  can  be  transmitted  to  monkeys  and  the  failure  to  find 
visible  and  stainable  parasites  in  the  lesions  of  the  spontaneous  and 
experimental  disease  led  to  another  line  of  investigation.  It  is  known 
that  the  viruses  of  vaccinia  and  rabies,  neither  of  which  has  been 
certainly  demonstrated  in  films  or  sections  of  tissue,  nor  cultivated 
artificially,  withstand  very  well  the  action  of  glycerin,  while  bacteria 
withstand  it  far  less  well. 

"\Ye  therefore  suspended  in  glycerin  the  comminuted  spinal 
cords  of  monkeys  affected  with  poliomyelitis,  and  after  an  interval 
of  days  we  have  inoculated  the  glycerinated  virus  into  normal  mon- 
keys. Monkey  No.  35  developed  paralysis  on  the  tenth  day  after 
inoculation,  with  characteristic  lesions  in  the  brain  and  cord.  Mon- 
key No.  58  was  then  injected  with  the  cord  of  monkey  Xo.  35  and 
developed  paralysis  on  the  eleventh  day. 

"The  next  series  of  experiments  were  planned  to  determine  the 
probable  size  of  the  organism  producing  poliomyelitis,  so  far  as  this 

could  be  accomplished  by  the  use  of  mechanical  filters 

Cord  was  triturated  with  sterile  quartz  sand,  mixed  with  salt  solution, 
thoroughly  shaken  and  pressed  through  a  Berkefeld  filter.  The  clear 
and  sterile  filtrate  was  injected  intracerebrally  into  Monkey  Xo.  68. 
which  developed  paralysis  on  the  seventh  day  following. 

"From  the  foregoing  experiments,  taken  in  conjunction  with  the 
negative  results  of  bacteriologic  and  histologic  examinations,  it  would 
appear  that  the  infecting  agent  of  epidemic  poliomyelitis  belongs  to 
the  class  of  the  minute  and  filterable  viruses  that  have  not  thus  far 
been  demonstrated  with  certainty  under  the  microscope.'' 


ETIOLOGY    OR    CAUSE    OF    INFANTILE    PARALYSIS.         25 

In  a  later  publication  Flexner  states:— 

"The  virus  in  aqueous  suspension  passes  with  readiness  and 
little  or  no  loss  of  potency  through  the  pores  of  the  densest  and  finest 
porcelain  niters,  namely,  the  so-called  Chamberland  filter.  It  passes 
with  even  greater  ease  through  the  somewhat  less  dense  Berkefeld 
filter.  It  is  extremely  doubtful  if  the  virus  has  actually  been  seen. 

"The  filtrates  are  highly  potent.  Quantities  as  small  as  one  one- 
thousandth  to  one  one-hundredth  of  a  cubic  centimeter  suffice  to 
cause  paralysis  in  monkeys  after  the  usual  incubation  period  when 
injected  into  the  brain.  The  virus  is  highly  resistant  to  external 
agencies  and  conditions.  It  withstands  glycerination  for  weeks  or 
months.  It  withstands  drying  over  caustic  potash  for  weeks  or 
months  without  any  or  marked  reduction  in  potency.  It  retains  its 
virulence  for  weeks  on  being  kept  frozen  at  minus  2°  to  4°  C.  On 
the  other  hand  it  is  readily  injured  by  heating,  since  temperatures  of 
45°  to  50°  C.  maintained  for  half  an  hour  render  the  filtrate  in- 
capable of  causing  paralysis.  That  the  virus  is  a  living  organism 
must  be  concluded  from  the  fact  that  such  minute  quantities  of  it 
suffice  to  carry  infection  through  an  indefinite  series  of  animals." 

The  filterable  virus  theory  of  Flexner's,  whose  proba- 
bilities rested  on  the  foregoing  demonstrations, 
( a )   Xo  visible  or  stainable  bacterial  nor  protozoal  para- 
sites. 
(  b )   Infective  virus  said  to  have  passed  with  readiness 

through  the  densest  and  finest  porcelain  filters, 
was  greatly  nullified  by  the  fact  that 

(a)  Many  investigators  found  organisms,  similar  in  their 

differences  from  all  known  bacteria,  freely  present 
in  the  spinal  fluid  drawn  from  poliomyelitis  cases. 

(b)  Pure   cultures   of  these   organisms  induced   experi- 

mental paralysis  in  various  animals. 

(c)  The  virus  was  not  filterable  through  Reichel  filters. 

(Leiner  and  Wiesner.) 

IV.  Di.von's  Protozoan. — The  State  of  Pennsylvania 
during  the  summer  of  1910  suffered  from  an  extensive 


26  INFANTILE    PARALYSIS. 

epidemic  of  poliomyelitis  of  1000  reported  cases.  Drs. 
Dixon,  Fox  and  Rucker,  of  the  State  Department  of 
Health,  began  a  series  of  independent  experiments  which 
were  carried  on  for  some  months,  and  the  results  pub- 
lishecl  as  a  State  Laboratory  report  March  2,  1911.  This 
valuable  report  is  given  in  part  :— 

"In  examining  the  blood  from  acute  cases  of  poliomyelitis 
(human  and  monkey)  an  organism  was  found  differing  in  mor- 
phological characteristics  from  any  heretofore  described.  The 
bloods  examined  were  taken  from  10  cases  of  acute  poliomyelitis  in 
children,  and  during  the  acute  stage  from  13  monkeys  in  which  the 
disease  had  been  artificially  produced.  Defibrinated  blood,  three 
weeks  to  two  months  old,  slwu'ed  the  organisms  in  increased  num- 
bers. Cultures  of  blood  from  paralyzed  monkey  in  blood-bouillon, 
plain  bouillon,  and  blood-agar,  examined  after  having  been  inoculated 
three  \veeks,  showed  the  forms  in  increased  numbers.  Filtered  rirns 
shoived  none  of  these  organisms.  Blood-smears  from  3  normal 
human  beings  gave  negative  results.  Smears  from  the  blood  of  13 
normal  monkeys  gave  negative  results;  after  inoculation  with  the 
virus  the  blood  of  these  monkeys  gave  positive  results.  Blood-smears 
being  fixed  and  stained,  the  organism  was  seen  to  be  free  in  the 
serum  as  well  as  in  the  body  of  the  red  blood-cell.  Stained  with 
carbol-thionin  the  organism  appeared  faintly  colored  with  a  finely 
granular  protoplasm ;  size,  ten  microns  long  by  about  eight  microns 
wide ;  shape,  curved  at  an  angle  of  sixty  degrees,  with  the  curved 
end  at  times  bulbous.  The  stain  with  iodine  and  sulfuric  acid  for 
cellulose  was  negative.  Search  for  moving  organisms  in  the  fresh 
blood,  defibrinated  blood,  and  blood-bouillon  was  also  negative." 

These  experiments  suggested  to  the  workers  that  the 
organism  with  which  they  were  dealing  was  a  protozoon, 
the  conclusion  at  which  Knoepfelmacher,  of  Germany,  had 
arrived  during  experimental  w'ork  with  the  organism. 
Beneke,  of  Marburg,  while  examining  hanging-drop  prep- 
arations of  infected  blood,  on  two  occasions  found  small, 
rapidly  moving  bodies.  Beneke  also  demonstrated  Gram- 
positive  bodies  in  the  pia  and  sections  of  the  cord,  removed 
post  mortem  from  human  cases  of  poliomyelitis.  There 


ETIOLOGY   OR   CAUSE   OF    1XFAXTILE    PARALYSIS.         27 

is  one  more  point  in  Beneke's  experimental  work  which 
is  suggestive ;  he  succeeded  in  infecting  3  rabbits  with 
poliomyelitis  by  introducing  a  solid  portion  of  fresh,  in- 
fected cord  intradurally  in  I  rabbit,  and  in  the  abdomen 
of  the  2  remaining;  the  third  rabbit  developed  convulsive 
movements  and  paralysis;  they  all  died;  and  although  no 
changes  could  be  demonstrated  in  the  brain  or  spinal  cord 
of  any  of  the  animals,  there  was  much  hemosiderin  de- 
posited in  the  spleen  of  each. 

Three  points  in  Beneke's  work  lend  strong  support  to 
the  Dixon  protozoon  theory  :— 

(a)  The  demonstration  of  rapidly  moving  bodies  in 
the  infected  blood. 

(b)  The  demonstration  of  organisms  in  the  section  of 
pia  and  cord. 

(c)  The  demonstration  of  hemosiderin  in  the  spleen 
of  three  infected  rabbits. 

Protozoa. — Protozoa  are  one-celled  animals  which 
have  crossed  the  border  line  dividing  the  viabje  from  the 
vegetable  world.  All  forms  of  bacteria  remain  in  the 
vegetable  kingdom. 

There  are  several  divisions  of  protozoa  classified  ac- 
cording to  their  morphology  and  other  characteristics: 
( i )  Rhizopoda,  named  for  their  means  of  locomotion,  of 
which  the  ameba  is  the  most  familiar  example.  (2)  The 
flagellates,  including  the  trypanosomes  and  spirochetes, 
whose  movements  are  undulating  and  whiplike.  (3)  In- 
fusoria, interesting  historically  in  that  Jennings  first  found 
in  one  of  their  number  "what  must  be  considered  the 
beginnings  of  intelligence,  and  of  many  other  qualities 
found  in  the  higher  animals."  (4)  Sporozoa,  the  spore- 
forming  protozoa,  of  which  Doane  writes:  "Xo  other 
group  of  animals  is  being  studied  more  today  by  both 
physicians  and  biologists." 


28  INFANTILE    PARALYSIS. 

The  trypanosomes  are  causative  factors  of  sleeping 
sickness,  and  the  epidemic  paralysis  of  domestic  animals 
in  Asia  which  is  known  as  surra,  as  well  as  other  epidemic 
diseases.  The  spirochetes  are  of  especial  interest  to  the 
student  of  poliomyelitis,  as  it  was  Xoguchi's  discovery  of 
the  proper  media  for  the  culture  of  Sfnroch&ta  pallida 
which  has  enabled  him  to  (January,  1913)  present  to  the 
scientific  world  pure  cultures  of  the  organism  of  acute 
poliomyelitis.  The  organism  of  syphilis  was  grown  suc- 
cessfully in  pure  culture  only  when  sterile  (living)  tissue 
was  added  to  the  ascitic  culture  media,  and  similarly  a 
pure  culture  of  the  poliomyelitis  organism  was  produced. 
There  has  been  some  discussion  as  to  whether  the  spiro- 
chetes arc  true  protozoa,  but  Xuttall  has  shown  that  they 
should  be  classed  on  the  animal  side  of  the  line. 

Sporozoa. — Protozoa  which  are  capable  of  taking  on 
a  resting  stage  during  which  the  encysted  organism  de- 
velops great  resistance  to  destructive  agencies  are  known 
as  spore-for,ming.  Sporozoa  are  motile  during  the  active 
stage;  they  may  develop  flagellre  or  propel  themselves 
about  by  means  of  pseudopodia;  they  are  not  dependent 
on  the  blood-stream  for  locomotion,  but  migrate  through 
the  body  tissues  as  do  the  white  blood-corpuscles.  The 
polymorphous  character  of  protozoa  is  well  shown  in 
Fantham's  study  of  a  small  flagellate  protozoon  (Hcrpcto- 
nwnas  pcdiculi}  which  inhabits  the  alimentary  tract  of 
the  louse.  Fanthani  presents  drawings  of  28  modifica- 
tions in  form  of  this  one  organism;  the  major  changes  are 
from  an  oval,  pre-flagellate  form  to  an  elongated  flagellate 
form,  and  post-flagellate,  small,  oval  and  encysted  resting 
stage. 

Means  of  Transmission  of  Protozoa  Outside  of  the 
Body. — It  is  now  recognized  that  various  members  of  the 
protozoon  family  are  the  occasion  of  most  of  the  infectious 


ETIOLOGY    OR    CAUSE    OF    INFANTILE    PARALYSIS.         29 

transmissible  diseases  of  man,  that  the  source  of  the  in- 
fection is  commonly  inoculation,  and  that  inoculation  is 
commonly  produced  by  a  blood-sucking  insect.  The 
Director  of  the  Lister  Institute  of  Preventive  Medicine, 
Dr.  C.  J.  Martin,  recently  stated: — 

Spirochetes  are  such  obligatory  parasites  that  the  agency  of  an 
insect  transmitter  seems  almost  necessary.  The  only  certain  way  of 
producing  the  disease  (relapsing  fever)  is  by  inoculating  a  minute 
quantity  of  the  blood  of  a  patient  during  the  febrile  stage.  (Martin, 
"Insect  Porters  of  Infections,"  British  Medical  Journal,  Jan.  4  and 
11,  1913.) 

Epidciniological  Endorsement  of  Dixon's  Protozoan 
Theory. — It  is  a  conspicuous  fact  that  most  of  the  proto- 
zoa which  have  been  identified  with  disease  were  found 
in  the  tropics  or  semitropics,  and  proved  to  be  the  exciting 
agent  of  some  so-called  tropical  disease.  The  plasmodium 
of  malaria  cannot  be  considered  as  an  exception,  because 
its  most  virulent  forms  are  found  to  exist  in  tropical 
regions.  The  paralysis  which  is  epidemic  among  domestic 
animals  in  North  America  coincidently  with  epidemics 
of  human  poliomyelitis,  is  clinically  related  to  an  epidemic 
paralysis  which  is  very  destructive  to  domestic  animals 
in  tropical  Asia  which  is  known  as  surra.  A  similar  dis- 
ease called  nagana  decimates  the  domestic  animals  of 
tropical  Africa.  These  tropical  epidemic  paralyses  are 
known  to  be  occasioned  by  a  trypanosome  transmitted  by 
biting  flies.  Should  one  of  these  diseases  of  domestic 
animals  at  the  tropics  extend  its  range  to  domestic  animals 
and  man  in  the  temperate  zone,  marching  to  the  north  in 
step  with  summer,  it  would  probably  make  a  heavy  in- 
vasion during  the  hot  weather,  and  check  rapidly  as  the 
oncoming  of  frost  destroyed  its  customary  environment. 
The  tropical  disease  might  remain  an  endemic  infection 
in  insect  or  human  carriers,  dormant  until  the  return  of 


30  IXFAXTILE    PARALYSIS. 

summer  restored  activity  and  virulence  to  its  exciting 
organism.  A  study  of  many  epidemics  demonstrates  that 
in  just  this  manner  poliomyelitis  is  manifested.  Poliomye- 
litis, which  is  sporadic  in  winter  in  the  temperate  zone, 
becomes  epidemic  in  the  early  summer  and  increases  to 
maximum  occurrence  in  the  month  of  August.  The  most 
severe,  epidemics  known  to  occur  appeared  simultaneously 
with  seasons  of  unusual  and  prolonged  heat  and  drouth 
in  Scandinavia,  North  America,  and  England,  and  les- 
sened with  the  cessation  of  extreme  heat,  a  considerable 
period  of  time  before  natural  agencies  (frost  and  cold 
rains)  checked  the  impetus  of  insect  fecundity. 

THE  PLEOMORPHIC   SPIROCHETE   OF  RABIES. 

The  clinical  analogy  of  epidemic  poliomyelitis  to  epi- 
demic rabies  is  striking.  The  clinician  notes  the  strong 
analogy  both  in  symptoms  and  progress  of  paralysis,  and 
death  occasioned  by  paralysis  of  respiration,  which  occurs 
in  both  poliomyelitis  and  rabies.  The  Pasteur  treatment 
is  not  infrequently  followed  by  a  temporary  pandysis.  and 
Landry's  paralysis  has  been  a  sequel  of  this  serum  treat- 
ment. 

Proescher,  of  Pittsburg,  who  has  given  four  years' 
time  to  the  demonstration  of  micro-organisms  in  rabies, 
announced  the  definite  etiologic  factor  of  this  disease. 
January,  1913,  as  follows:— 

Proescher  was  convinced  that  rabic  virus  must  be 
microscopically  visible  because  (a)  he  had  found  it  non- 
filterable,  and  (b)  there  was  no  diminution  in  the  virus 
of  a  rabic  dog  which  had  been  buried  eight  months.  He 
was  able  by  careful  technique  to  demonstrate  organism^ 
in  smears  from  the  following  sources:— 

(a)  A  smear  from  the  brain  of  an  infected  rabic  rabbit 
killed  in  the  paralytic  stage. 


ETIOLOGY   OR   CAUSE   OF   INFANTILE   PARALYSIS.         31 


Smears  from  the  brains  of  12  dogs  infected  on 
the  street,  whose  rabic  state  was  demonstrated  by  trans- 
mission to  other  animals. 

(c)  Smears  from  the  salivary  gland  and  nerve-gan- 
glion of  a  cow  (proved  rabic  by  transmission  of  infection 
to  other  animals). 

(d)  Smears    from    the    salivary    glands    of    3    dogs 
(proved  rabic  by  transmission  to  laboratory  animals). 

(e)  From  fixed  virus  obtained  from  four  Pasteur  In- 
stitutes in  America  (U.  S.  Marine  Hospital,  Washington, 
D.  C.  ;  Chicago;  New  York;  Alexander's). 

Smears  and  sections  stained  with  a  I  per  cent,  carbo- 
azur-carbonate  (Unna-Giemsa)  demonstrated  the  "entire 
cycle''  of  rabies  virus,  cocci  and  bacilliforms,  and  spiro- 
chetes.  These  pleomorphic  germs  showed  an  achromato- 
philia  to  all  aniline  stains  except  the  azur-carbonate. 
Proescher  considers  that  the  pleomorphism  is  satisfactorily 
interpreted  as  developmental  forms  of  one  organism,  the 
resting,  active,  motile  and  spore  stages.  The  bacilliforms 
were  bipolar,  one-half  to  one  micron  in  length  and  one- 
third  micron  thick,  isolated,  or  arranged  in  chains  and 
groups  ;  besides  these  small  bacilliforms,  there  were  larger, 
•  >val  or  round  forms.  It  was  remarkable  that  often  a 
larger  form  was  found  at  one  end  of  the  chain,  and  the 
succeeding  ones  gradually  diminished  in  size  to  a  very 
minute  form.  Proescher,  noting  that  the  biologic  proper- 
ties of  rabies  were  akin  to  those  of  poliomyelitis,  made 
smears  from  the  cervical  cord  of  a  case  of  poliomyelitis; 
stained  with  azur-carbonate  the  smear  showed  a  great 
number  of  coccilike  forms,  although  the  culture  taken 
from  the  same  media  two  hours  after  death  remained 
absolutely  sterile. 

In  these  researches  we  again  have  evidence  of  the 
protozoan  origin  of  a  disease  closely  allied  to  or  perhaps 


32  INFANTILE    PARALYSIS. 

only  a  modified  form  of  acute  poliomyelitis  in  the  human 
being.  A  certain  degree  of  intelligence  seems  to  be  ex- 
hibited by  motile  protozoa  which  congregate  in  the  sali- 
vary passages  of  blood-sucking  insects,  from  which  point 
they  most  readily  gain  access  to  the  blood-stream  of  the 
obligate  host.  Such  intelligence  or  response  to  stimuli 
would  indicate  that  the  organism  belonged  in  the  class 
of  quickened,  protoplasmic,  motile,  one-celled  animals, 
grouped  as  protozoa,  rather  than  among  the  bacteria. 

SUCCESSFUL  CULTIVATION  OF  THE  PLEOMORPHIC 
PROTOZOAN   OF    POLIOMYELITIS. 

Proescher's  suggestive  announcement  of  the  identifi- 
cation of  the  pleomorphic  spirochete  of  rabies,  January 
4,  1913,  was  followed  in  February  by  the  announcement 
that  Noguchi,  making  use  of  the  technique  by  him  de- 
veloped in  the  growth  of  the  SpirocJiccta  pallid  a,  obtained 
pure  cultures  of  the  organism  of  poliomyelitis. 

Xoguchi's  technique  is  given  in  his  standard  of  identifi- 
cation of  Spirochccta  pallida:  (a)  presence  of  sterile 
fresh  tissue  in  culture  media;  (b)  strict  anaerobiosis. 

In  a  solid  medium  consisting  of  I  part  of  ascitic  fluid 
and  2  parts  of  weakly  alkaline  agar  containing  a  piece  of 
sterile  fresh  tissue,  the  Spirochata  pa!  I  id  a  grew  slowly 
and  steadily  around  the  tissue  and  formed  faint,  diffuse 
colonies. 

The  report  of  Noguchi's  cultivation  and  identification 
of  the  organism  of  poliomyelitis  follows:— 

The  cultivations  have  been  conducted  both  with  Berkefeld  fil- 
trates (of  poliomyelitis  emulsion)  and  (poliomyelitic)  tissues  in 
substance.  The  culture  mediums  consist  (first)  of  sterile,  unfiltered 
ascitic  fluid  or  of  brain  extract  to  which  fragments  of  sterile  rabbit 
kidney  and  a  layer  of  paraffin  oil  have  been  added,  and  of  these  plus 
2  per  cent,  nutrient  agar-agar  in  proportions  of  I  to  2.  The  first 


ETIOLOGY   OR   CAUSE   OF    IXI-AXTILE    PARALYSIS.         33 

mediums  permit  of  a  slow  growth  not  visible  to  the  naked  eye,  while 
the  second  (which  are  unsuitable  for  obtaining  the  initial  growth) 
yield,  after  several  days,  visible  minute  colonies  clouding  the  tubes. 
The  cultivations  are  conducted  under  anaerobic  conditions,  and  the 
colonies  do  not  ascend  to  the  summit  of  the  deep  layer  of  solid 
medium. 

The  minute  colonies  are  composed  of  globular  or  globoid  bodies, 
averaging  in  young  cultures  0.15  to  0.3  micron  in  size.  The  bodies 
appear  in  a  variety  of  arrangements :  single,  double,  short  chains  and 
masses.  Often  they  appear  embedded  in  a  material  of  different  re- 
fractive index.  In  older  cultures  certain  bizarre  forms  have  been 
noted.  The  cultivated  bodies  stain  a  pale  reddish  violet  in  Giemsa's 
solution,  and  bodies  of  identical  appearance  have  been  demonstrated 
by  Xoguchi,  also  with  Giemsa's  solution,  by  a  specially  devised 
method  in  films  prepared  directly  from  the  nervous  tissues. 

Monkeys  have  been  inoculated  with  the  cultures.  Two  series 
of  inoculations  have  been  made  and  a  third  series  is  in  progress. 
Cultures  from  human  tissues  in  the  third  and  from  monkey  tissues 
in  the  fifth  generation  have  caused  typical  experimental  poliomyelitis 
in  the  monkey.  The  findings  at  autopsy  and  the  microscopic  appear- 
ances of  sections  of  the  spinal  cord,  medulla  and  intervertebral 
ganglia  were  characteristic  of  the  disease.  From  the  nervous  tissues 
of  these  animals  other  monkeys  were  successfully  inoculated  and 
pure  cultures  recovered.  (Jour.  Amer.  Med.  Assoc.,  Feb.  I,  1913.) 

It  will  be  noted  that  Xoguchi  found  the  organism  of 
poliomyelitis  taken  from  young  cultures  globose  in  out- 
line and  very  minute  (less  than  half  of  one  micron  in 
size);  while  in  older  cultures  the  bizarre  forms  recorded 
-u^gest  at  once  the  entire  cycle  of  developmental  change 
in  morphology  of  the  rabic  organism  demonstrated  by 
Proescher.  In  addition  the  cultivated  globose  bodies  and 
similar  organisms  in  films  prepared  from  the  spinal  cord, 
medulla,  and  intervertebral  ganglia  were  successfully 
<lyed  by  the  azur-carbonate  (Giemsa)  stain  used  by 
Proescher  to  demonstrate  the  rabic  organism. 

Xoo;uchi's  work  confirms  (i)  Giersvold,  who  first  suc- 
iv-sfully  cultivated  the  organism  of  poliomyelitis;  (2) 


34  INFANTILE    PARALYSIS. 

IJcnckc,  who  cultivated  it  in  living  anaerobic  tissues  by 
inclosing  bits  of  infected  cord  in  the  peritoneum  of  a  living 
rabbit;  (3)  Proescher,  who  demonstrated  organisms  in 
tissue  of  cervical  cord  from  a  case  of  poliomyelitis  In- 
staining  with  the  Giemsa  azur-carbonate ;  and  many  other 
investigators  of  Europe  and  North  America. 

CHARACTERISTICS  OF  THE  ORGANISM  OF  EPIDEMIC 
POLIOMYELITIS. 

From  the  foregoing  it  may  be  deduced  that  the  etio- 
logic  factor  of  acute  poliomyelitis  is  a  pleomorphic,  motile, 
anaerobic,  pathogenic,  obligative  hemoprotozoon ;  with  a 
developmental  cycle  consisting  of  a  resting,  motile,  divid- 
ing, and  resistant  spore  stage;  which  elaborates  a  virus 
having  a  destructive  affinity  for  myelin  and  susceptible  t<> 
great  augmentation  and  modification;  capable  of  pure  cul- 
ture in  an  anaerobic  preparation  of  a  solid  or  fluid,  sterile, 
living  body  tissue;  reacting  specifically  to  the  azur-carbon- 
ate dye;  bearing  a  strong  clinical  and  histologic  analogy 
to  rabies;  pathogenic  to  man  and  domestic  animals:  en- 
demic in  the  tropics;  epidemic  in  the  tropics  and  in  the 
temperate  zone  during  the  summer  season ;  pandemic  under 
conditions  of  prolonged  heat  and  drouth  and  other  un- 
known factors  most  favorable  for  its  wide  diffusion. 

EXPERIMENTAL  TRANSMISSION   TO   MONKEY. 

Acute  poliomyelitis  was  first  successfully  transmitted 
to  monkeys  by  Landsteiner  and  Popper,  in  i<jo8,  by  in- 
traperitoneal  inoculation  of  an  emulsion  of  the  spinal  cord 
of  a  boy  who  died  of  poliomyelitis.  They  failed  to  trans- 
mit the  disease  from  the  first  to  a  second  series  of  monkeys 
at  that  time.  In  October,  1909,  Drs.  Flexner  and  Lewis 
produced  the  experimental  disease  in  monkeys  by  intra- 
cerebral  inoculation  of  a  triturate  of  the  spinal  cord  of  j 


ETIOLOGY   OR   CAUSE   OF    IXFAXTILE    PARALYSIS.         35 

victims  of  the  disease.  They  successfully  retransmitted 
the  disease  to  successive  relays  of  monkeys,  until  a  series 
of  25  had  been  produced.  In  April,  1910,  by  the  courier 
of  Dr.  Flexner,  Director  of  Rockefeller  Research  Labora- 
tory, the  writer  was  shown  this  epoch-making  line  of 
investigation.  In  numerous  cages,  lining  a  large  and  airy 
room,  were  monkeys,  each  of  which  presented  one  or  more 
of  those  deforming  disabilities  previously  seen  to  develop 
among  children  and  adults  of  North-central  Wisconsin. 
This  .sight  was  one  of  the  rare  gratifications  of  life. 


Fig.  5. — Experimental  paralysis  of  all  four  extremities  in  monkey. 
(After  Router.) 

This  will  be  understood  by  every  doctor  in  an  invaded 
community,  who,  convinced  that  he  was  facing  an  epi- 
demic of  a  communicable  disease,  had  yet  no  authoritative 
proof  to  offer  to  indifference,  prejudice,  and  cupidity  that 
the  disease  was  infective  and  transmissible,  and  demanded 
urgent  and  immediate  isolation,  improved  sanitation,  and 
other  prophylaxis,  to  check  its  advance. 

The  analogy  these  apes  presented  to  the  cases  in 
human  beings  was  curious  and  startling.  There  were 
inaii\-  paralyses  of  extremities,  with  the  typical  attendant 
atrophies  and  contractures.  One  had  wrist-drop ;  another. 
a  Hail  arm.  There  was  a  grotesque  case  of  paralysis  of 
the  facial,  with  dropped  jaw.  One  big  male  was  paralyzed 


36 


INFANTILE    PARALYSIS. 


from  the  flanks  down,  yet  climbed  about  in  his  cage  with 
surprising  agility,  dragging  the  atrophied  limbs,  less  help- 
less than  a  child  with  paraplegia. 

The  original  material  used  for  these  inoculations  was 
obtained,  post  uwrtcni,  from  2  children  who  died  during 
the  acute  stage,  I  on  the  third,  and  the  other  on  the  sixth 


Fig.  6. — Experimental  facial  patalysis  (right)  in  monkey. 
(After  Romer.) 

day  succeeding  the  appearance  of  the  paralysis.  The 
virus  from  these  cases  was  continuously  transferred 
through  series  of  monkeys,  becoming  more  active  during 
each  successive  inoculation.  It  could  apparently  be  trans- 
ferred indefinitely.  Here  was  proof  that  infantile  paral- 
ysis is  an  infectious  disease,  caused  by  a  living  organism 
capable  of  reproduction  in  the  body  of  its  host.  The  po- 
tencv  of  a  chemical  toxin  would  be  so  diminished  bv  re- 


ETIOLOGY    OR   CAUSE   OF    INFANTILE    PARALYSIS. 


37 


peated  dilution  and  division  as  to  be  wholly  inert,  and  a 
chemical  substance  has  no  power  of  multiplication  nor 
reproduction. 

The  progress  of  the  disease  in  the  ape  was  a  close 
analogue  of  the  affection  in  a  human  being.  The  virus, 
a  solution  of  the  spinal  cord  of  a  victim,  was  usually  in- 


Fig.  7. — Experimental  right  oculomotor  paralysis  in  monkey. 
(After  Romer.) 

troduced  through  a  trephine  opening  into  the  brain-pan. 
\Yhen  the  ape  recovered  from  the  anesthesia,  he  appeared 
in  every  way  normal  for  a  period  of  time  varying  from 
four  to  thirty  days.  After  a  few  days  he  was  seen  to  be 
listless  for  a  few  hours,  or  with  no  marked  symptoms  of 
onset ;  he  became  ill  with  great  suddenness.  The  paralysis 
appeared  in  from  two  hours  to  forty-eight  hours  follow- 
ing the  period  of  incubation.  The  paralysis  in  more  than 
one -half  of  the  cases  affected  the  lower  extremities,  and 


38 


IXl-AXTILE    PARALYSIS. 


otherwise  varied  in  extent,  location,  and  degree  as  it  does 
in  human  beings.  In  some  of  the  monkeys,  lightly  af- 
fected, there  was  motor  weakness  only,  followed  by  re- 
covery. In  some  cases  the  paralysis  extended  upward  with 
bulbar  involvement,  paralysis  of  respiration,  and  death. 
The  mortality  rate  constantly  increased  with  an  apparent 


Fig.  8. — Experimental  paralysis  of  right  hind  leg  in  monkey. 
(After  Romer.) 

increase  of  the  virulence  of  the  virus  until  it  reached  100 
per  cent,  of  the  animals  inoculated. 

The  disease  has  been  transmitted  to  monkeys  by  other 
investigators,  and  by  other  methods.  Strauss  and  Hun- 
toon,  Leiner  and  Wieser,  Romer,  and  Landsteiner  and 
Leviditi,  have  all  successfully  transmitted  the  disease  to 
apes.  An  emulsion  of  the  infected  cord  has  been  success- 
fully injected  into  the  meninges.  the  nerves,  the  nerve- 
sheaths,  and  the  peritoneum.  The  disease  has  been 


ETIOLOGY    OR   CAUSE   OF    IXFAXT1LE    PARALYSIS. 


39 


caused  by  the  artificial  introduction  into  the  stomach  and 
intestine  of  some  of  the  emulsion ;  this  latter  method  was 
successful  only  when  peristalsis  was  controlled  by  opium. 
The  disease  has  been  caused  by  rubbing  an  emulsion  of 
the  cord  on  the  mucous  membrane  of  the  nasal  passages 
after  scarification  of  the  same:  by  application  to  the  intact 


Fig.  9. — Experimental  facial  paralysis  (right)  in  monkey. 
(After  Romer.) 

(  ?)  nasal  mucosa;  by  enforced  inhalation  of  an  emulsion 
<>f  an  infected  cord,  and  by  subcutaneous  inoculation. 

In  the  body  tissues  the  virus  has  been  demonstrated 
t<>  be  present  in  the  blood  and  spinal  fluid  during  the  early 
-luge  or  onset  of  disease.  It  has  been  found  in  the  sali- 
vary, mesenteric,  and  other  lymph-glands,  and  the  spleen. 
It  is  supposed  to  be  eliminated  by  the  feces.  Kling  and 
I'etterson  demonstrated  that  the  intestinal  mucosa  of  a 
case  was  infective. 


40 


IXFAXTILE    PARALYSIS. 


Poliomyelitis  has  been  transmitted  to  monkeys  by 
many  experimenters;  to  rabbits,  to  guinea-pigs,  and  to 
pigeons.  From  infected  rabbits  the  disease  has  been  trans- 
mitted to  other  rabbits,  and  also  to  monkeys.  Experimen- 
tation with  other  animals  and  fowls  has  so  far  failed  to 
reproduce  the  disease.  The  failure  to  inoculate  cats,  dogs, 


Fig.  10. — Experimental  paralysis,  facial  and  hypoglossal,  in  monkey. 
(After  Romer.) 

sheep,  and  horses  with  this  disease  is  probably  due  to  some 
lack  of  technique  in  the  artificial  inoculation,  for  evidence 
accumulates  that  many  domestic  animals  are  simultane- 
ously attacked  during  an  epidemic  among  human  beings. 
(See  Chapter  I.)  It  may  be  due  to  an  acquired  immunity. 
When  Pasteur  wished  to  increase  virulence  in  a  patho- 
genic germ  he  inoculated  a  day-old  guinea-pig.  It  is 
probable  that  the  young  laboratory  animal  would  prove 
susceptible  when  the  adult  remained  resistant 


ETIOLOGY    OR    CAUSE    OF    IXKAXT1LE    PARALYSIS.         41 

METHOD  OF  TRANSMISSION  OF  THE  MICRO-ORGAN- 
ISM OF  ACUTE  POLIOMYELITIS  (A)  FROM 
ANIMAL  TO  MAN;  (B)  FROM 
MAN  TO  MAN. 

("I  eat  and  keep  silence."  A  literal  translation  of  the  natirc 
name  for  an  Egyptian  blood-sucking  fly.}  There  is  but  a  single  layer 
of  epithelium  between  us  and  death,  and  the  bite  of  an  insect  pierces 
the  barrier. 

Two  years  before  the  final  identification  of  the  specific 
micro-organism  of  poliomyelitis  by  Noguchi,  several  in- 
vestigators, including  Frost,  of  the  Public  Health  Service ; 
Mills  and  Dixon,  of  Pennsylvania,  and  Manning,  of  Xc\\ 
York,  suggested  that  the  probable  agent  of  transmission 
of  this  disease  was  a  blood-sucking  insect.  The  summer 
of  1912  Sheppard  and  Rosenau,  of  Massachusetts,  con- 
firmed this  theory  by  the  successful  transmission  of  the 
disease  from  monkey  to  monkey  by  the  biting  stable-fly, 
Stojuo.vys  calcit rans.  Their  work  with  the  biting  fly  was 
immediately  reconfirmed  by  Anderson  and  Frost,  of  the 
Public  Health  Service.  The  reports  are  given  later.  The 
agency  of  the  stable-fly  accounts  satisfactorily  for  the 
transmission  of  epidemic  paralysis  from  animal  (espe- 
cially the  horse)  to  man.  Manning,  in  the  face  of  much 
opposition,  announced  and  maintained  that  the  bedbug, 
Ciinc.r  lectularius,  was  the  logical  and  usual  carrier  of 
poliomyelitis  from  man  to  man.  Van  Gieson's  (unpub- 
lished )  experiments  with  the  bedbug  and  poliomyelitis 
were  all  negative.  Howard  and  Clark  announced,  in 
December,  1912,  that  bedbugs,  seven  days  from  feeding 
on  poliomvelitic  monkey,  contained  sufficient  active  virus 
to  paralyze  and  cause  death  in  a  healthy  monkey  in  which 
it  was  injected.  It  now  seems  probable  that,  in  addition 
to  the  stable-fly  and  the  bedbug,  other  blood-sucking  in- 
sects may  be  implicated  in  the  transmission  of  the  disease. 


42  INFANTILE    PARALYSIS. 

Langhorst,  of  Illinois,  has  reported  2  cases  apparently 
due  to  direct  inoculation  from  the  dog. 

Inoculation. — The  experimental  production  of  polio- 
myelitis in  animals  has  been  achieved  only  by  some  method 
of  inoculation.  It  has  never  been  secured  where  a  pos- 
sible abrasion  and  therefore  a  wound  surface  could  be 
absolutely  ruled  out.  The  routine  method  of  experimen- 
tation has  been  the  injection  of  an  emulsion  of  infected 
tissues  into  the  trephined  brain  of  a  monkey.  Experi- 
menters claim  to  have  produced  the  disease  by  applying 
virus  to  the  unabraded  mucous  surface  of  the  nares,  but 
if  one  delicate  mucous  cell  was  denuded  in  this  process  an 
inoculation  atrium  was  thereby  established. 

As  the  successful  production  of  experimental  polio- 
myelitis depended  on  inoculation,  it  seemed  reasonable  to 
expect  that  spontaneous  cases  also  arose  from  inocula- 
tion. Advocates  of  the  contagion  theory  were  at  a  loss 
to  account  for  the  fact  that  spontaneous  transmission 
among  laboratory  monkeys  was  never  known  to  occur,  and 
the  comparative  rarity  of  multiple  cases  in  families, 
secondary  cases  in  institutions,  and  the  lessened  incidence 
of  the  disease  in  winter,  the  period  when  nasopharyngeal 
contagions  multiply.  Not  only  was  experimental  trans- 
mission of  the  disease  dependent  on  inoculation,  but  the 
greatest  incidence  of  the  disease  in  epidemic  form  ap- 
peared during  that  season  of  the  year  when  insect  life 
reached  the  maximum.  Observation  of  these  facts  led  to 
the  following  investigations:— 

STOMOXYS  CALCITRANS. 
(The  Stable-fly.    The  Biting  Fly.    The  Barn-fly.    The  Rain-fly.) 

Owing  to  the  frequent  histories  of  insect  bites  of  various  kinds. 
it  was  deemed  advisable  that  the  entomological  part  of  field  work 
should  be  thoroughly  investigated.  There  is  a  negative  evidence 


ETIOLOGY   OR   CAUSE   OF    IXFAXT1LE    PARALYSIS.         43 

afforded  by  the  failure  of  investigators  to  satisfactorily  account  for 
the  spread  of  infantile  paralysis  through  other  channels  of  infection. 

Reports. — Waltham,  2  cases,  i  in  a  very  unsanitary  house  in  the 
yard  of  which  many  stomoxys  were  seen  ten  days  after  the  patient 
became  paralyzed. 

Twekesbury,  State  Infirmary,  6  cases.  Usual  domestic  insects 
were  observed,  also  an  abundance  of  stomoxys,  some  of  which  were 
seen  upon  a  screened  enclosure  in  the  grounds  in  which  the  children 
had  frequently  been  placed  before  they  were  attacked. 


Kip.  11.— The  Stable-fly;  Barn-fly;  Rain-fly.    (Stomoxys  calcitrant.) 

\\~oburn.  14  cases.  Epidemic  paralysis  of  pigs.  Paralyzed  cat. 
Stable-flies. 

Somerville,  10  cases.  Usual  series  of  domestic  insects,  including 
stomoxys.  In  I  case  a  history  was  obtained  that  one  month  before 
the  attack  in  July  the  child  was  stung  between  the  shoulders  by  a 
strange  insect,  about  8  o'clock  in  the  evening,  and  at  the  same  time 
an  adult  member  of  the  family  was  bitten  the  same  way.  The  sting 
was  accompanied  by  a  very  sharp  pain  and  was  probably  the  bite  of 
some  species  of  tabanus  (horse-fly),  although  it  may  have  been 
>t«moxys  or  some  other  biting  insect. 

Xewton,  4  cases.  Several  cows  lame  in  hind  quarters.  Biting 
flies. 


44  INFANTILE    PARALYSIS. 

Winchester.  2  ca-os.     Stomoxys  seen  in  abundance. 

Pocasset.  2  cases.  Usual  domestic  insects,  including  stomoxys 
and  small  horse-fly. 

Hamilton,  i  case.    Biting  flies. 

Marblehead,  i  case.  An  insect  described  as  resembling  a  tick 
had  been  seen  on  the  infant  and  had  bitten  it.  Stomoxys  had  been 
killed  in  patient's  bedroom. 

Marlboro,  3  cases.  Stomoxys  abundant  about  premises  and 
barnyard,  also  seen  in  house  and  bedrooms  of  patients. 

Lowell,  14  cases.     Paralyzed  cat.     Stomoxys. 

Westford,  I  case.    Mosquitoes  and  stomoxys. 

Winchendon,  i  case.    Houseflies  and  stomoxys. 

New  Bedford,  4  cases.    Stomoxys. 

Fall  River,  13  cases.  Stomoxys.  One  child  had  marks  of  bites 
on  his  body.  An  interesting  case  in  an  adult  male,  73  years  old,  was 
seen,  who  gave  a  history  of  bites  by  stable-flies,  followed  in  a  week 
by  febrile  attack  and  paralysis  of  one  arm.  ("Biting  Insects  and 
Infantile  Paralysis,"  Sheppard  and  Brues,  Mass.  Jour,  of  Economic 
Entomology,  August,  1912.) 

The  stable-fly  Stomoxys  calcitrant,  which  is  common 
to  Europe  and  America,  is  closely  related  to  the  tse-tse  flies 
both  in  structure  and  habits.  It  has  been  quite  definitely 
associated  with  the  spread  of  surra,  and  may  reasonably 
be  suspected  of  transmitting  any  disease  represented  by 
organisms  in  the  blood.  This  fly  has  been  found  in  the 
environs  of  practically  every  case  of  infantile  paralysi> 
examined  by  us  with  this  end  in  view,  and  may  quite  pos- 
sibly prove  to  be  the  insect  responsible  for  its  spread. 

Many  facts  connected  with  the  distribution  of  cases, 
together  with  histories  of  insect  bites,  suggest  that  the 
disease  may  be  insect  borne.  Field  work,  together  with 
the  epidemiology  of  the  disease  so  far  as  known,  points 
strongly  toward  biting  flies  as  possible  carriers. 


ETIOLOGY   OR   CAL'SE   OF    1XFAXTILE   PARALYSIS.         45 

TRANSMISSION    OF   POLIOMYELITIS    BY   MEANS    OF 
THE  STABLE-FLY  (STOMOXYS  CALCITRANS). 

Bv  JOHN  F.  ANDERSON,  DIRECTOR  HYGIENIC  LABORATORY.  AND  \\  AUK  H.  FROST, 
PASSED  ASSISTANT  SURGEON,  UNITED  STATES  PUULIC  HEALTH  SERVICE. 

As  a  result  of  the  thorough  epidemiologic  studies  of  poliomyelitis 
conducted  by  the  Massachusetts  State  Board  of  Health  from  1907  to 
1912,  under  the  direction  of  Dr.  Mark  \Y.  Richardson,  secretary  of 
the  board,  evidence  was  collected  which  led  the  investigators  to 
strongly  suspect  that  the  common  stable-fly  (Stomoxys  calcitrant) 
played  an  important  part  in  the  spread  of  this  disease. 

At  the  joint  session  of  sections  I  and  V  of  the  Fifteenth  Inter- 
national Congress  on  Hygiene  and  Demography  in  \Yashington,  Sept. 
26,  1912,  Dr.  Milton  J.  Rosenau.  of  the  Harvard  Medical  School, 
who  has  been  working  in  conjunction  with  the  Massachusetts  State 
I'.oard  of  Health,  announced  the  result  of  an  experiment  which 
seemed  to  confirm  most  strikingly  the  inferences  drawn  from  the 
epidemiologic  work  above  mentioned. 

Dr.  Rosenau  stated  that  he  had  infected  several  monkeys  with 
poliomyelitis  by  intracerebral  inoculation,  exposed  them  daily — from 
the  time  of  inoculation  till  death — to  the  bites  of  several  hundred 
stomoxys,  at  the  same  time  exposing  12  fresh  monkeys  to  the  bites 
of  the  same  flies.  At  the  time  the  announcement  was  made  6  of  these 
12  monkeys  were  reported  as  having  developed  symptoms  character- 
istic of  poliomyelitis,  i.e.,  illness  followed  by  more  or  less  extensive 
paralysis.  Of  these  6  monkeys  2  had  died,  3  were  paralyzed  at  that 
time,  and  i  recovered  after  a  brief  illness.  In  the  cord  of  one  of 
the  monkeys  that  had  died  \vere  found  the  characteristic  lesions  of 
poliomyelitis,  that  is,  perivascular  infiltration  and  destruction  of  the 
motor  cells  of  the  anterior  cornu.  The  cord  of  the  other  monkey 
was  reported  to  have  shown  changes  less  characteristic  of  polio- 
myelitis, namely,  degenerations  of  the  motor  cells  without  perivas- 
cular infiltration. 

At  the  time  of  announcement  a  sufficient  interval  had  not  elapsed 
to  determine  the  result  of  the  attempt  to  transmit  the  infection  to 
other  monkeys  by  inoculation  with  the  cord  of  one  of  the  two  that 
had  died. 

This  experiment,  giving  an  altogether  new  direction  to  the  ex- 
perimental study  of  poliomyelitis,  appeared  of  sufficient  importance 
to  warrant  an  immediate  attempt  at  confirmation. 


46  1X1-AXTILE    PARALYSIS. 

In  the  experiment  below  reported  it  has  been  our  object  to  re- 
peat the  conditions  of  that  reported  by  Rosenau,  and  we  are  indebted 
to  him  for  assistance  and  advice  in  the  details  of  the  experiment. 

On  October  3,  rhesus  Xo.  242  was  inoculated  intracerebrally 
with  an  emulsion  of  the  cord  of  a  monkey  which  had  died  of  polio- 
myelitis. The  virus  used  is  a  strain  originally  obtained  from  the 
Rockefeller  Institute  for  Medical  Research,  kept  at  the  hygienic 
laboratory  for  nearly  two  years,  during  which  time  it  has  been 
passed  through  a  large  series  of  monkeys. 

Two  hours  after  inoculation  the  infected  monkey  was  exposed 
to  the  bites  of  about  300  stomoxys  recently  collected  in  Washington. 
Thereafter  until  death,  on  October  8,  this  animal  was  exposed  daily 
for  about  two  hours  to  the  bites  of  the  same  flies,  plus  additional 
fresh  stomoxys  added  from  time  to  time  as  caught.  This  monkey 
(No.  242)  developed  characteristic  complete  paralysis  on  the  after- 
noon of  October  7  and  died  at  2  A.M.  October  8. 

Another  monkey  (rhesus  Xo.  246),  similarly  inoculated  on 
October  5,  was  then  exposed  daily  to  the  bites  of  the  same  flies. 
beginning  October  7.  This  monkey  developed  paralysis  on  the  morn- 
ing of  October  9,  soon  becoming  completely  paralyzed  and  dying  that 
afternoon. 

Thus,  from  October  4  to  October  9,  inclusive,  the  flies  used  had 
access  to  two  monkeys  inoculated  with  poliomyelitis  ;  first,  rhesus  X'  >. 
242,  then  rhesus  Xo.  246.  It  may  be  noted  that  the  incubation  period 
in  both  these  monkeys  was  very  short — four  days  from  inoculation 
to  the  development  of  paralysis. 

Beginning  October  4,  two  fresh  monkeys  (rhesus  Xo.  243  and 
Java  No.  241)  were  exposed  daily  for  about  two  hours  to  the  bites 
of  these  same  flies ;  and  beginning  October  5  a  third  fresh  monkey 
(rhesus  Xo.  244)  was  similarly  exposed.  All  three  of  these  animal- 
subsequently  developed  symptoms  of  poliomyelitis,  as  follows : — 

Java  Xo.  241  was  found  completely  paralyzed  on  the  morning  nf 
October  12  and  died  a  few  hours  later.  At  autopsy  tubercles  were 
found  in  the  lungs,  liver,  and  spleen. 

Rhesus  No.  244  showed  paralysis  of  the  hind  legs  on  the  same 
day  (October  12),  but  was,  nevertheless,  exposed  again  to  the  bites 
of  the  stomoxys  from  10  A.M.  till  2  P.M.  At  3  P.M.  the  animal,  being 
almost  completely  paralyzed,  was  chloroformed.  At  autopsy  tuber- 
cles were  found  in  the  lungs,  liver,  and  spleen,  but  apparently  not 
sufficient  to  have  been  the  cause  of  death. 


ETIOLOGY   OR   CAUSE   OF    INFANTILE    PARALYSIS.        47 

Rhesus  Xo.  243,  which  had  appeared  well  on  the  morning  of 
October  13,  was  found,  at  4  o'clock  that  afternoon,  to  have  a  partial 
paralysis  of  the  right  hind  leg.  The  following  morning  the  hind  legs 
and  right  fore  leg  were  almost  completely  paralyzed.  My  3.30  P.M. 
the  neck  also  was  paralyzed  and  the  intercostal  muscles  somewhat 
affected.  The  animal  was  then  chloroformed.  At  autopsy  the  in- 
ternal organs  appeared  normal,  except  the  spinal  cord,  which  was 
edematous,  the  gray  matter  being  congested.  Sections  of  the  cord, 
histologically  examined,  showed  typical  well-marked  lesions  of  polio- 
myelitis; perivascular  round-cell  infiltration;  foci  of  dense  infiltra- 
tion in  the  gray  matter  of  the  anterior  horn ;  and  destruction  of  some 
of  the  motor  neurons. 

The  histologic  examination  of  the  cords  of  monkeys  Nos.  241 
and  244  has  not  yet  been  completed,  but  it  is  believed,  on  the  clinical 
evidence,  that  they  died  of  poliomyelitis. 

To  summarize:  three  monkeys  exposed  daily  to  the  bites  of 
several  hundred  stomoxys,  which  at  the  same  time  were  allowed 
daily  to  bite  two  intracerebrally  inoculated  monkeys,  developed  quite 
typical  symptoms  of  poliomyelitis  eight,  seven  and  nine  days,  re- 
spectively, from  the  date  of  their  first  exposure. 

In  order  to  confirm  the  diagnosis  of  poliomyelitis  in  rhesus  Xo. 
243,  i  cubic  centimeter  of  an  emulsion  of  the  cord  of  this  monkey 
was  injected  intracerebrally  on  October  14  into  a  healthy  monkey 
(rhesus  No.  250).  This  animal  recovered  promptly  from  the  opera- 
tion and  remained  apparently  quite  well  till  the  morning  of  October 
17,  when  a  partial  paralysis  of  the  right  fore  leg  was  noted,  pro- 
gressing somewhat  during  the  day.  On  the  morning  of  October  18 
both  fore  legs  were  completely  paralyzed  and  the  hind  legs  weak. 
In  the  afternoon  of  the  same  day  the  right  hind  leg  was  completely 
paralyzed,  the  left  very  weak,  and  the  neck  paralyzed.  The  monkey 
died  at  10.30  P.M.  and  was  immediately  placed  on  ice  until  autopsy 
could  be  made  at  9  A.M.,  October  19. 

At  the  autopsy  there  was  found  some  congestion  of  the  lower 
lobe  of  both  lungs,  most  marked  on  the  left  side,  upon  which  the 
animal  had  been  lying  after  paralysis  developed.  The  meninges  of 
the  cord  were  markedly  congested.  On  section,  the  cord  appeared 
edematous,  and  the  gray  matter  congested,  showing  minute  hemor- 
rhages. The  site  of  inoculation  appeared  normal  except  for  a  slight 
clot.  Cultures  from  this  site  have  shown  no  growth.  The  other 
organs  were  normal  in  appearance. 


48  INFANTILE    PARALYSIS. 

Histologic  examination  of  the  cord  showed  lesions  characteristic 
of  poliomyelitis,  intense  congestion  and  perivascular  infiltration,  foci 
of  round-cell  infiltration  here  and  there  in  the  gray  matter,  destruc- 
tion of  the  cells  of  the  anterior  cornu,  and  small  hemorrhages  in  the 
anterior  and  posterior  cornu. 

CONCLUSION. 

These  results,  in  confirmation  of  those  announced  by  Dr.  Rose- 
nau,  would  seem  to  demonstrate  conclusively  that  poliomyelitis  may 
be  transmitted  to  monkeys  through  the  agency  of  the  stable-fly 
(Stomo.vys  calcitrans) . 


CIMEX  LECTULARIUS. 

(The  Bedbug.     Chinchbug.     Wall  Louse.     B  Flat. 
Mahogany  Flat.) 

At  a  certain  stage  of  the  study  of  the  epidemic  trans- 
mission of  acute  poliomyelitis  the  writer  (Manning)  found 
it  compulsory  to  investigate  the  habits  of  the  bedbug.  It 
was  found  to  be  the  accredited  agent  of  transmission  of  a 
number  of  blood-borne  diseases:  typhoid  fever  (Dutton), 
tuberculosis  (Rose),  kala  azar  or  dumdum  fever  (Patton), 
leprosy  (Goodhue,  Kerr),  relapsing  fever  (Sergeius),  in- 
fantile kala  azar  (Gabbi),  bubonic  plague  (Verjbitski). 

The  most  extensive  and  instructive  investigation  of 
the  bedbug  to  be  found  in  medical  literature  was  that 
undertaken  by  Verjbitski,  a  Russ  engaged  in  research  in 
the  Laboratory  of  the  Imperial  Institute  of  Experimental 
Medicine  at  St.  Petersburg,  whose  report  w:as  translated 
and  published  in  the  Journal  of  Hygiene.  Verjbitski's  re- 
searches related  to  the  spread  of  bubonic  plague,  but  their 
results  are  so  amazing,  that  the  epidemiologist  endeavoring 
to  trace  the  progression  of  any  blood-borne  disease,  and 
the  physician  likewise  engaged  will  feel  well  repaid  for 
time  spent  on  the  brief  precis  appended : — 


ETIOLOGY   OR   CAUSE   OF    INFANTILE   PARALYSIS.         49 

Yerjbitski's  results  were  definite,  proving  that  bedbugs  fed  on 
animals  dying  of  plague  communicated  the  plague  to  guinea-pigs  for 
five  days  afterward ;  fleas  fed  on  animals  dying  of  plague  com- 
municated the  plague  to  other  animals  for  three  days.  Verjbitski 
says  in  his  report:  "These  experiments  were  conducted  with  guinea- 
pigs.  The  plague  culture  was  enhanced  in  virulence  by  passing 
through  several  guinea-pigs.  The  bugs  used  were  Cimc.r  Icctularins. 
which  is  the  usual  domestic  parasite.  The  strong  irritation  occa- 
sioned by  its  bite  is  caused  by  the  action  of  the  saliva  which  is  in- 
jected into  the  wound.  A  bug  never  inflicts  but  one  bite,  and  does 
not  leave  the  place  until  it  has  filled  itself  with  blood.  Its  body  under 
these  conditions  acquires  an  egg-shaped  form.  The  bedbugs,  in 
series  of  50,  were  applied  to  guinea-pigs  dying  of  plague,  and  to  an 
area  of  skin  under  the  thigh  which  had  previously  been  shaved. 
The  results  definitely  proved  that  the  bedbug  transmits  plague,  and 
that  as  an  agent  of  such  transmission  the  bedbug  is  to  be  more 
feared  than  the  much-dreaded  flea  of  man  and  animals." 

Yerjbitski's  summary,  under  fifteen  heads,  of  the  results  of  the 
60  recorded  experiments  is  here  given:  "(i)  All  bedbugs  and  fleas 
which  have  sucked  the  blood  of  animals  dying  from  plague  contain 
plague  microbes.  (2)  Bedbugs  and  fleas  which  have  sucked  the 
blood  of  animals  suffering  from  plague  contain  plague  microbes  only 
when  the  bite  is  inflicted  twelve  to  twenty-six  hours  before  death, 
that  is,  during  that  period  when  the  blood  contains  plague  bacillus. 
(3)  The  vitality  and  virulence  of  the  plague  microbe  are  preserved 
in  these  insects.  (4)  The  plague  bacillus  is  found  in  bugs  which  are 
not  starved,  one  to  seven  days ;  in  bugs  previously  starved  four 
months,  they  are  found  eight  to  nine  days.  (5)  The  number  of 
plague  bacilli  increases  the  first  few  days.  (6)  The  feces  of  the 
infected  bug  or  flea  contain  virulent  plague  bacilli  as  long  as  they 
persist  in  the  alimentary  canal  of  the  insect.  (7)  The  more  virulent 
the  culture  with  which  is  inoculated  the  first  animal  on  which  the 
bug  was  fed,  the  more  certainly  the  infection  was  conveyed  by  bites. 
(8)  The  local  inflammatory  reaction  in  animals  which  died  from 
plague  occasioned  by  bites  of  infected  insects  was  very  slight  or 
absent.  In  the  latter  case  one  could  only  locate  it  by  the  situation 
of  the  primary  bubo.  (9)  Infected  bugs  communicated  disease  to 
healthy  animals  five  days;  fleas,  three  days.  (10)  Not  more  than 
two  animals  were  infected  from  the  same  bug.  (n)  Crushing  of 
infected  bugs  in  situ  in  process  of  biting  occasioned,  in  the  majority 


50  INFANTILE    PARALYSIS. 

of  cases,  the  infection  of  healthy  animals.  (12)  Injury  to  the  skin 
occasioned  by  the  bite  of  the  bug  or  flea  offers  a  channel  through 
which  the  plague  bacillus  can  easily  enter  the  body  and  occasion 
deaths  from  plague.  (13)  Crushed  infected  bugs  and  their  feces  can 
infect  small  punctures  of  the  skin  caused  by  bites  for  a  short  time 
after  infliction  of  bites.  (14)  On  linen  soiled  by  crushed  bedbugs 
(or  fleas)  or  their  infected  feces  the  plague  bacillus  can  under  favor- 
able conditions  remain  alive  and  virulent  for  five  months.  (151 
Chemical  disinfectants  do  not  in  the  ordinary  course  of  application 
kill  the  plague  bacillus  in  the  infected  bug  or  flea. 

"In  crushed  infected  bugs  the  plague  bacillus  preserved  its  mor- 
phologic characteristics  during  all  the  time  it  was  found  in  the  bodies 
of  bugs.  In  the  midst  of  a  great  mass  of  well-preserved  blood-cor- 
puscles could  be  seen  an  enormous  quantity  of  plague  bacilli  in  alim»t 
pure  culture.  Experiment  XLII:  The  inner  surface  of  the  hind 
leg  in  6  guinea-pigs  was  scratched  three  times  with  a  fine  needle  and 
the  crushed  bug  was  rubbed  over  the  scarification ;  all  of  the  6  pigs 
died  of  plague  in  forty-seven  to  sixty-nine  hours.  Pure  cultures  of 
plague  bacilli  were  obtained  from  the  following  source- :  (  i  >  the 
crushed  infected  bugs  on  bits  of  linen — (a]  dried  thirty-five  days  at 
room  temperature,  (b)  one  hundred  and  thirty  days  in  damp  environ- 
ment at  4  to  5°  C,  (c)  exposed  during  eight  days  to  direct  sunlight. 
and  (d)  frozen  ten  days  at  5°  C.  to  18°  C. ;  and  (2)  from  the  feces 
of  bugs  which  had  been  allowed  to  dry  on  linen  at  room  temperature 
for  ten  days.  These  were  all  verified  by  the  inoculation  of  guinea- 
pigs.  From  the  results  we  must  conclude  that  clothing  and  bed- 
clothes which  are  soiled  with  material  from  infected  insects,  obtained 
either  by  crushing  them  or  from  their  feces,  can  serve  during  a  long 
time  as  a  source  of  infection.  The  clothing  of  people  who  live  in 
dirty,  unhygienic  surroundings  is  generally  covered  with  spots  from 
crushed  bugs  and  their  feces." 

The  following  description  of  the  bedbug  is  quoted 
from  the  bulletin,  The  Bedbug,  of  the  U.  S.  Entomological 
Bureau  :— 

The  bedbug  has  accompanied  man  wherever  he  has  gone.  Ves- 
sels  are  almost  sure  to  be  infested  with  it.  It  is  not  limited  by  cold. 
The  presence  of  the  bedbug  in  a  house  is  not  necessarily  an  indication 
of  neglect,  for.  little  as  the  idea  may  be  relished,  this  insect  may  often 


ETIOLOGY   OR   CAUSE    OK    IXFAXTILE    PARALYSIS. 


51 


gain  access  in  spite  of  all  reasonable  precautions.  It  is  apt  to  get 
into  the  trunks  and  satchels  of  travelers.  It  migrates  from  one 
house  to  another,  sometimes  for  a  period  of  several  months,  gaining 
entrance  daily.  Migration  is  apt  to  take  place  if  the  inhabitants  of 
an  infested  house  leave  it.  With  the  failure  of  their  usual  source  of 
food  the  bedbugs  pass  along  walls,  water-pipes  and  gutters,  and  gain 
entrance  to  adjoining  houses.  The  bedbug  is  thoroughly  nocturnal  in 
habits  and  displays  wariness,  or  intelligence,  in  its  efforts  at  conceal- 
ment during  the  day.  It  usually  leaves  the  bed  at  the  approach  of 
daylight,  to  go  into  concealment  in  cracks  in  the  bedstead,  or  be- 
hind wainscoting,  or  under  loose  wall-paper,  manifesting  its  gre- 


Fig.  12. — Bedbug  (Cimex  lectnlariits)  :  Egg  and  newly  hatched 
larva :  a,  larva  from  below ;  b,  larva  from  above ;  c,  claw ;  d,  egg ; 
e,  hair  or  spine  of  larva.  Greatly  enlarged,  natural  size  of  larva  and 
egg  indicated  by  hair  lines  (original).  (U.  S.  Circular  No.  47,  "The 
Bedbug." ) 

garious  habit  by  collecting  in  masses.  The  inherited  experience  of 
many  centuries  of  companionship  with  man  has  resulted  in  a  knowl- 
edge of  the  habits  of  the  human  animal,  and  a  facility  of  conceal- 
ment, particularly  as  evidenced  by  its  abandoning  beds  and  often 
going  to  distant  quarters  for  protection  and  hiding  during  daylight. 
The  bedbug  belongs  to  the  order  Hemiptera,  characterized  by 
possessing  a  piercing  and  sucking  beak.  The  bedbug,  though  nor- 
mally feeding  on  human  blood,  is  able  to  get  more  or  less  sustenance 
from  the  juices  of  moistened  wood,  or  the  moisture  in  the  accumula- 
tions of  dust,  etc.,  in  crevices  in  flooring.  The  biting  organs  of  the 
bedbug  consist  of  a  heavy  underlip  within  which  lie  four  thread-like, 


52 


1X1. \XTILE    PARALYSIS. 


hard  filaments,  which  glide  over  each  other  with  an  alternating  motion 
and  pierce  the  flesh.  The  blood  is  drawn  up  through  the  beak, 
which  is  closely  applied  to  the  point  of  puncture,  and  the  alternating 
motion  of  the  setae  in  the  flesh  cause  the  blood  to  flow  more  freely. 
In  common  with  other  insects  which  attack  man,  these  pests  may  be 
the  transmitters  of  contagious  (?)  diseases.  The  bite  of  the  bedbug 
is  poisonous  to  some  individuals.  To  such  the  presence  of  the  bugs 
is  sufficient  to  cause  the  greatest  uneasiness.  \Yith  others,  however. 
the  presence  of  the  bugs  may  not  be  recognized  at  all,  and  except 


Fig.  13. — Bedbug  (Cimex  lecfularius}  :  a,  adult  female,  gorged 
with  blood ;  b,  same  from  below ;  c ,  rudimentary  wing  pad  ;  d,  mouth 
parts,  a,  b,  much  enlarged;  c,  d,  highly  magnified  (original).  (U.  S. 
Circular  No.  47,  ''The  Bedbug.") 

for  the  occasional  staining  of  the  linen  by  a  crushed  individual  their 
presence  might  be  entirely  overlooked.  The  bedbug  is  known  to  be 
able  to  survive  for  long  periods  without  food.  In  unoccupied  houses 
it  can  undoubtedly  undergo  fasts  of  extreme  length.  Individuals 
obtained  from  eggs  have  been  kept  in  sealed  vials  in  this  office  for 
several  months,  remaining  active,  in  spite  of  the  fact  that  they  had 
never  taken  any  nourishment  whatever.  Bedbugs  are  said  to  lay 
several  batches  of  eggs  during  the  season  and  are  extremely  prolific. 
The  eggs  are  white,  oval  objects,  and  are  laid  in  batches  of  one-half 
dozen  to  fifty  in  cracks  and  crevices  where  the  bugs  go  for  conceal- 
ment. The  eggs  hatch  in  a  week  or  ten  days.  Breeding  experi- 


ETIOLOGY   OR   CAUSE   OF    INFANTILE    PARALYSIS.         53 

ments  conducted  at  this  office  indicate  seven  weeks  as  the  period  from 
egg  to  adult  insect. 

Are  bedbugs  a  common  factor  in  American  homes? 
In  each  of  the  following  instances  I  have  observed  bed- 
bugs in  large  numbers :  ( I )  Having  had  occasion  to  trace 
the  source  from  which  bedbugs  were  found  on  a  white 
infant  in  a  Xorth  Carolina  home,  T  investigated  the  sleep- 
ing quarters  of  the  colored  cook  and  maid ;  the  bed-frame 
under  the  mattress  in  each  bed  was  a  crawling,  seething 
mass  of  bedbugs.  (2)  Tracing  to  their  source  the  bed- 


Fig.  14. — Alimentary  canal  and  mouth  parts  of  bedbug  (Cimex 
lectularius}.  ("Insect  Porters  of  Bacterial  Diseases,"  Dr.  C.  J. 
Martin,  Director  Lister  Institute  Preventive  Medicine.) 

bugs  which  appeared  in  a  scrupulously  kept  medical  ward 
of  Cook  County  Hospital,  Chicago,  I  found  the  bed  of  the 
kitchen  man,  which  he  had  previously  made  and  "bugged" 
himself,  alive  with  bedbugs.  The  bed-frame,  drawn  out 
on  the  concrete  floor,  was  swabbed  with  alcohol  and  then 
fired,  when  the  bedbugs  literally  boiled  out  of  every  joint 
in  the  iron.  (3)  Attending  at  night  an  obstetric  case  in 
a  tenement  while  externe  at  the  Chicago  Lying-in  Dis- 
pensary, I  found  hundreds  of  these  crawlers  descending 
the  board  partition  which  formed  one  side  of  the  room. 
Called  to  the  apartment  of  an  unknown  woman  at  night,  I 
found  her  bedclothing  swarming  with  bedbugs.  Compos- 
ing myself  to  sleep  in  a  richly  upholstered  reclining  chair 


54  1. \FAXTII.K    PARALYSIS. 

on  a  train  in  the  Southwest  in  late  October  I  was  at  once 
attacked  by  bedbugs  in  such  numbers  that  all  portions  of 
the  body  felt  as  if  scorched  with  flame. 

Observation  demonstrates  that  constant  distribution 
of  the  bedbug  among  members  of  the  various  social  classes 
takes  place:  the  physician  returns  from  the  slum  case  and 
the  lawyer  from  the  court  where  bedbugs  swarm;  the  maid 
takes  her  half-day  in  a  tenement  home,  the  daily  paper  is 
distributed  by  a  tenement  dweller,  the  hand  laundry  often 
returns  from  a  tenement  district ;  the  vacation  is  spent  in 
unfumigated  summer  camps,  and  the  traveler's  bag  or 
trunk  is  a  usual  hiding  place  for  cimex;  men,  women,  and 
children  of  all  social  classes  come  in  close  contact  in  rail- 
road stations,  transit  lines,  theaters,  schools,  moving 
picture  entertainments,  summer  amusements,  and  public 
inns.  The  invasion  of  the  American  home  is  more  suc- 
cessfully accomplished  by  the  gentle  art  of  concealment 
practised  by  the  retiring  but  ubiquitous  bedbug. 

Such  instances  as  the  following  are  difficult  to  explain 
by  any  theory  of  personal  contact,  direct  or  indirect  :— 

"In  a  sporting  camp  in  a  northern  forest  the  5-year-old 
son  of  the  proprietor  had  been  in  camp  since  early  spring. 
He  had  never  left  the  camp  during  the  summer.  The 
camp  was  five  miles  front  any  other  camp  or  house  and  ten 
miles  from  the  frontier  town.  There  had  been  no  other 
children  in  camp  during  the  summer  and  no  illness  of  any 
kind  in  the  few  guests  or  among  animals.  The  few  guests 
who  were  there  came  from  the  large  cities,  put  on  their 
hunting  and  fishing  clothes,  and  lived  out  of  doors.  In 
October  the  child  developed  a  typical  infantile  paralysis 
which  still  persists  in  one  leg."  (Lovett  and  Richardson.) 

The  foregoing  occurrence  is  readily  explained  by  the 
assumption  that  an  infected  bedbug  found  its  way  to  a 
guest's  garments  while  en  route,  and  later  attacked  the  buy. 


ETIOLOGY    OK    CAUSE    OF    INFANTILE    PARALYSIS.         55 

GEOGRAPHIC    RANGE    OF   CIMEX. 

Acute  poliomyelitis  has  been  reported  in  epidemic  form 
from  every  continent  during-  the  past  decade:  Europe, 
A>ia,  Africa,  Australia,  North  and  South  America.  It 
therefore  seemed  well  to  ascertain  the  range  of  the  insect 
suspected  of  transporting-  the  disease.  English  scientists 
in  England  and  India  term  it  the  Indo-European  bedbug; 
Yerjbitski  states  that  it  is  commonly  found  in  the  homes 
of  the  insanitary  Russian  peasant ;  L.  Lodian,  an  Ameri- 
can engineer  employed  on  the  construction  of  the  Siberian 
Railroad,  wrote:  "I  tell  you,  the  Siberian  gentry  are 
almost  as  large  as  our  roaches,  and  their  bite  leaves  an 
inflamed  poison  wheal  about  one-half  the  size  of  a  hazel- 
nut.  Experienced  travelers  often  prefer  to  lay  their  rugs 
<>n  the  floor  and  sleep  there,  taking  the  precaution,  how- 
ever, to  empty  the  contents  of  a  kerosene  lamp  on  the 
floor  in  a  sort  of  sanitary  cordon;  inside  that  ring  they 
can  sleep  with  some  degree  of  immunity  from  the  bed- 
bugs." Miss  Underwood,  a  returned  missionary,  states 
that  while  in  China,  after  a  brief  daytime  nap,  the  gown 
might  be  mottled  with  bedbugs.  Bedbugs  are  found  in 
Australia.  Tn  Africa  the  danger  of  association  with  cimex 
is  so  well  known  by  the  common  people  that  caravan  tents 
are  known  as  "bugwalks,"  and  avoided  by  men  hiking  to 
the  diamond  fields.  The  bedbug  is  a  Pan-American  pest. 

BURDEN    OF    PROOF    THAT    CIMEX    CARRIES 
POLIOMYELITIS. 

It  has  been  said  that  any  insect,  to  merit  consideration 
as  an  obligatory  factor  in  the  transmission  of  poliomyelitis, 
must  be  of  (i)  worldwide  distribution  (as  poliomyelitis  is 
pandemic),  (2)  perennial  prevalence  (as  cases  occur 
throughout  year),  and  (3)  capable  of  wide  migrations 


56  INFANTILE    PARALYSIS. 

(as  often  there  is  a  wide  jump  between  cases),  to  which 
we  would  add  that  (4)  its  distribution  must  be  urban  as 
well  as  rural  (as  many  cases  in  city  as  country),  that  (5) 
it  must  show  a  marked  numerical  increase  in  summer 
(with  maximum  incidence  of  cases),  and  that  (6)  its  pre- 
ferred food  should  be  the  blood  of  man. 

1.  That  cimex  is  of  worldwide  distribution   may  be 
seen  by  reference  to  foregoing  paragraph  on  geographic 
range. 

2.  Perennial  prevalence.    Cimex  was  formerly  a  hiber- 
nating insect,  as  may  be  deduced  from  the  fact,  demon- 
strated by  the  United  States  Bureau  of  Entomology,  thai 
the  insect  could  endure  fasts  of  many  months'  duration, 
sealed   in  glass  tubes,   and  emerge  alive   and   vigorous. 
Modern  methods  of  artificial  heating  of  homes  in  winter, 
both  of  the   rich  and  poor,   and  domestication   in   these 
habitations   have   rendered  hibernation   unnecessary,    for 
shelter  and  food  are  obtainable  throughout  the  year.     In 
January,  1912,  the  writer  observed  an  adult  bedbug  mi- 
grating from  one  passenger  to  another  in  the  brilliantly 
electrified  coach  of  a  Hudson  tube.     This  migration  was 
taking  place  in  midwinter. 

3.  When  Flexner  placed  stress  on  the  factor  that  an 
insect,  to  convey  poliomyelitis,  must  be  capable  of  wide 
migration,  winged  insects  were  doubtless  in  mind.     With 
modern  transportation  methods,  an  insect  parasitic  to  man 
and  with  the  art  of  concealment  in  clothes,  etc.,  could  be 
carried  to  distances  beyond  the  power  of  the  winged  in- 
sect.   This  is  the  case  with  the  bedbug. 

4.  The  insect  must  have  an  equal  distribution  in  city 
and  country.     Many  cases  of  poliomyelitis  have  occurred 
in  city  homes  which  were  remote  from  stables,  greatly 
lessening  the  probability  that  the  child  had  been  exposed 
to  the  bite  of  the  stable-fly.     Some  statistics  have  been 


ETIOLOGY   OR   CAUSE   OF    INFANTILE   PARALYSIS.         57 

published  and  an  impression  has  gone  abroad  that  polio- 
myelitis is  a  disease  of  the  country  rather  than  of  the  town. 
Our  experience  in  a  city  clinic  inclines  us  to  the  belief  that 
this  statement  is  based  on  insufficient  data.  Sheppard,  of 
Massachusetts,  states  that  the  1911  epidemic  focused  in 
the  city  of  Springfield,  Mass. 

Bedbugs  abound  in  city  tenements.  The  cleanly  tenant 
is  at  the  mercy  of  his  uncleanly  neighbor,  and  they  are 
both  wholly  dependent  on  the  janitor,  for  the  efforts  of 
one  family  will  never  make  a  material  reduction  in  the 
number  of  bedbugs  in  a  building. 

5.  Marked  numerical  increase  in  summer.    The  maxi- 
mum incidence  of  poliomyelitis  occurs  during  July  and 
August  in  the  north  temperate  zone,  coincidental  with  the 
maximum  incidence  of  insects,   including  bedbugs.     On 
inquiry  the  writer  has  been  informed  by  several  house- 
keepers that  young,  newly  hatched,  white  bedbugs  are  seen 
only  at  this  season  in  temperate  zone. 

6.  Preferred  food,  the  blood  of  man.     The  common 
blood-sucking  parasites  of  man  are  the  bedbug,  louse,  flea, 
and  house  mosquito.     It  is  quite  possible  that  any  one  of 
these  insects  may  transmit  the  organism  of  poliomyelitis 
from  man  to  man.     As  poliomyelitis  occurs  any  month  in 
the  year,  it  is  doubtful  that  the  flea,  mosquito,  or  stable- 
fly,  which  are  all  annual  and  seasonable  and  disappear  at 
the  oncoming  of  frost,  could  be  the  common  carriers  of  the 
disease.    The  louse  may  also  be  excluded  from  considera- 
tion, as  it  is  found  only  among  that  class  of  citizens  whose 
members  are  grossly  unclean. 

COINCIDENTAL  PRESENCE  OF  BEDBUGS  AND 
POLIOMYELITIS. 

It  is  a  striking  fact  that  in  every  epidemiologic  investi- 
gation of  acute  poliomyelitis  in  which  a  careful  inquiry 


58  INFANTILE    PARALYSIS. 

has  been  made  regarding  the  presence  of  bedbugs,  they 
have  been  found  to  be  present.  As  this  insect  has  carried 
the  art  of  concealment  to  a  high  power,  it  is  certain  that 
they  are  present  and  unrecognized  in  still  more  cases  than 
those  reported. 

The  first  epidemiologist  to  make  vermin  a  matter  of 
routine  investigation  during  an  outbreak  of  poliomyelitis 
was  Lovett.  of  Massachusetts.  During  the  extensive  in- 
vasion of  190),  a  particular  investigation  was  made  of 
150  cases  which  occurred  in  142  families.  The  blood- 
sucking insects  found  present  are  given  in  the  following 
tables : — 

BITING  INSECTS  PRESENT  IN  HOMES  OF  150  CASES  OF 
ACUTE  POLIOMYELITIS. 

Fleas  were  present  in   2.  homes. 

Biting  flies  were  present  in 3  homes. 

Bedbugs  were  present  in  31  homes. 

Mosquitoes  were  present  in 75  homes. 

(Massachusetts,  1909.  Lovett,  Bull.  Mass.  State  Board  of 
Health,  June.  1910.) 

BITING  INSECTS  PRESENT  IN  HOMES  OF  200  CASES  OF  POLIO- 
MYELITIS OCCURRING  IN  185  FAMILIES. 

Sand-fleas  were  present  in i  home. 

Fleas  were  present  in 2  homes. 

Biting  flies  were  present  in   7  homes. 

Bedbugs  were  present  in 39  homes. 

Mosquitoes  were  present  in 67  homes. 

(Massachusetts.  1910.     Sheppard.) 

Dr.  Sheppard  adds  to  this  report :  "It  will  be  seen 
that  biting  insects  in  families  were  present  in  greater 
number  than  the  history  of  bites;  T  am  inclined  to  the 
belief  that  the  truth  as  to  bites  has  been  in  a  large  measure 
withheld."  (Sheppard,  Report  submitted  to  Massachu- 
setts State  Board  of  Health,  May  i,  IQII.) 


ETIOLOGY   OR   CAUSE   OF   INFANTILE    PARALYSIS.         59 

J.n  an  investigation  of  the  home  surroundings  of  33 
cases  of  acute  poliomyelitis  occurring  in  and  near  Xew 
York  City  during  1911,  which  were  treated  at  the  hospital 
of  Rockefeller  Institute,  bedbugs  were  found  present  seven 
times  in  all.  The  indifference  with  which  their  presence 
is  frequently  regarded  may  be  judged  from  the  statement 
of  one  father  that  the  "bedbugs  were  worse  in  the  chil- 
dren's room."  This  may  not  be  the  apathy  of  indifference, 
but  a  result  of  total  inability  to  cope  with  a  problem  which 
should  be  one  of  municipal  control,  rather  than  ineffectual 
individual  effort.  The  two  first  cases  quoted  illustrate  a 
point  the  writer  desired  to  make  clear,  that  this  vermin 
(cimex)  is  found  equally  distributed  in  city  and  country:— 

Case  5.  John  O.,  aged  21  months.  Paralysis  of  both  legs  com- 
plete;  left  forearm  weak.  Wristdrop.  Clawhand.  Tenement  house. 
Eleven  other  families  in  house.  Only  parasites  noted  are  bedbugs. 
The  father  states  that  these  are  worse  in  the  children's  room. 

Case  7.  James  C,  aged  18  months.  Complete  flaccid  paralysis 
of  both  legs.  Right  arm  weak.  Xeck  and  back  muscles  weak. 
Habitat,  four-family  house  in  the  country;  clean,  and  has  good  air. 
The  mother  states  that  there  "are  lots  of  bedbugs,  cockroaches,  and 
chicken-lice." 

Case  21.  Helen  N.,  aged  6  years.  Right  facial  paralysis.  Many 
water-bugs,  bedbugs,  and  fleas  in  West  Side  home. 

Case  32.  Patrick  T.,  aged  23  months.  Dragged  one  leg. 
Habitat,  second-floor-front  flat.  Father,  mother,  sister,  with  acute 
poliomyelitis,  and  patient  slept  in  one  room.  Flies,  mosquitoes,  bed- 
bugs, and  roaches.  (From  "A  Clinical  Study  of  Acute  Polio- 
myelitis," Peabody,  Draper,  and  Dochez.) 

A  history  of  insect  bites  is  not  infrequently  given  in 
cases  of  poliomyelitis.  In  Sheppard's  report  of  the  Massa- 
chusetts epidemic  of  1911,  it  is  said  that  an  "insect  re- 
sembling a  tick  had  been  seen  on  the  infant  and  had  bitten 
it  before  the  symptoms  of  poliomyelitis  developed."  The 
insect  which  "resembles"  a  tick  most  closely  is  the  bedbug. 


60  1XFAXTILE    PARALYSIS. 

The  following  suggestive  case  was  recently  reported 
by  Dr.  Spiller,  Professor  of  Xeuropathology,  University 
of  Pennsylvania: — 

In  another  case  of  epidemic  poliomyelitis,  seen  with  Dr.  W.  B. 
Stewart,  of  Atlantic  City,  a  bite  of  an  insect  produced  quite  a  severe 
sore  on  the  foot,  and  this  was  followed  in  a  few  days  by  paralysis. 
Whether  an  etiologic  relation  can  be  attributed  to  this  bite  or  not  is 
uncertain.  (Spiller,  Diagnosis  of  Poliomyelitis,  Penn.  Med.  Journal, 
December,  1911.) 

Professor  Spiller  has  most  kindly  provided  more  ex- 
tended notes  of  this  very  interesting  case  as  follows : — 

The  patient  was  a  girl.  14  years  of  age.  She  lived  in  Atlantic 
City,  over  a  store.  Atlantic  City  is  on  an  island.  She  had  gone  to 
the  mainland  on  a  picnic,  and  during  the  evening  was  bitten  by  some 
insect.  The  bite  was  on  the  foot,  and  within  a  few  days  the  sore 
was  sufficient  for  her  to  seek  medical  attention.  The  bite,  as  I  recall, 
was  on  a  part  usually  covered  by  a  shoe,  but  probably  she  had  on  a 
low  shoe.  A  few  days  after  she  was  bitten  she  developed  symptoms 
of  poliomyelitis.  The  paralysis  was  extensive  in  all  limbs.  No  case 
of  poliomyelitis  in  Atlantic  City  or  on  the  mainland  was  known  at 
that  time.  I  cannot  attribute  the  poliomyelitis  to  the  insect  bite. 

The  history  of  this  case  is  very  suggestive.  Cimc.r 
Icctularius  may  be  considered  a  permanent  resident  of  tene- 
ments and  insanitary  lodging  houses,  and  the  floating 
population  of  Atlantic  City  doubtless  fetch  and  carry 
many  members  of  his  family. 

The  possibility  of  direct  transmission  of  poliomyelitis 
from  the  acute  case  to  any  person  entering  the  patient's 
room  by  inoculation  from  a  bedbug  which  has  been  feeding 
on  the  patient  is  apparent.  Such  transmission  through  un- 
known agency  is  often  reported,  and  the  following  case  is 
suggestive  in  this  connection: — 

New  York  Hospital  for  Deformities  and  Joint  Diseases,  Polio- 
myelitis Clinic.  S.,  schoolgirl,  aged  9  years;  onset  May  i/th;  two 


ETIOLOGY   OR   CAUSE   OF    INFANTILE   PARALYSIS.         61 

clays  before  onset  visited  a  playmate  ill  with  poliomyelitis,  in  bed  and 
paralyzed ;  S.  was  reproved  by  her  sister  for  eating  food  which  was 
on  the  bed  of  the  sick  girl,  and  by  her  mother  for  the  same  reason 
when  she  returned  home.  Attack,  high  fever,  twitching,  symptoms 
of  ptomaine  poisoning,  general  spastic  condition,  succeeded  by  paral- 
ysis from  hips  down,  with  paresis  of  upper  extremities. 

The  well-known  habit  of  the  bedbug  of  crawling  from 
a  bed  to  the  clothing  of  any  person  coming  in  contact  with 
the  draperies  would  account  for  the  transmission  of  this 
disease  by  a  third  party  who  was  and  remained  a  healthy 
carrier.  The  agency  of  cimex  offers  a  possible  solution 
of  the  transmission  of  poliomyelitis  in  this  record,  ex- 
cerpted from  Dr.  John  Armstrong's  study  of  an  epidemic 
of  17  cases  in  a  small  community  in  Minnesota: — 

D.  W.,  female,  aged  5  years;  onset  August  6,  1909;  August  7th, 
paralysis  of  right  lower  leg. 

August  24th,  this  child  wras  visited  by  her  grandmother,  who 
on  August  26th  went  to  visit  another  grandchild,  residing  in  a  town 
in  which  no  poliomyelitis  had  developed.  A  third  grandchild  was 
temporarily  at  the  home  of  the  second.  The  third  child  became  ill, 
developing  a  paralysis  August  28th.  On  August  3Oth  the  second 
grandchild  became  ill  and  also  developed  a  paralysis.  Is  it  possible 
(Dr.  Armstrong  inquires)  the  grandmother  carried  the  infection  and 
transmitted  it  to  the  second  and  third  child?  (Armstrong,  Polio- 
myelitis, Pediatrics,  August,  1910.) 

It  would  be  difficult  to  prove  the  migration  of  cimex 
from  the  sick  child  to  the  well  grandmother,  but  that  such 
migration  takes  place  I  have  recently  had  proof: — 

The  evening  of  January  28,  1912,  returning  from 
Atlantic  City  on  the  Pennsylvania  Railroad,  we  trans- 
ferred to  the  Hudson  tube  at  Manhattan  Transfer.  The 
coaches  are  the  last  word  in  safe  and  sanitary  construction, 
being  made  throughout  of  steel  and  concrete.  Seats  ex- 
tend length  wise  of  the  coach.  Across  from  our  party  sat  a 
small  family  group  of  the  immigrant  class.  The  mother, 


62  IX  FAX  TILE    PARALYSIS. 

a  robust  creature  of  20  years,  held  a  small,  puny  infant,  in 
marked  contrast  to  her  own  buxom  appearance.  The  man, 
a  well-built  young  male,  'sat  limp  and  pallid,  with  his 
emaciated  hands  crossed  feebly  on  his  overcoat.  There 
were  several  bag's  disposed  about  them,  and  one  behind 
the  man's  feet. 

While  speculating  as  to  the  probable  illness  which  had 
so  depleted  this  young  foreigner,  my  eye  was  caught  by 
an  insect  which  crawled  out  on  the  floor  from  under  this 
bag.  It  was  a  fair-sized  bedbug.  It  advanced  across  the 
aisle  several  inches  and  returned  as  fast  to  shelter  when 
some  one  passed  down  the  aisle.  The  coaches  are  bril- 
liantly electrified  and  I  had  no  difficulty  in  watching  the 
maneuvers  of  this  pest.  Three  times  the  bug  essayed 
crossing  the  aisle,  and  each  time  returned  to  the  shelter 
of  the  bag,  as  people  entered  the  coach  at  stations.  The 
fourth  trip  cimex  came  directly  across  the  aisle;  when 
within  three  inches  of  the  clothing  of  two  ladies,  I  crushed 
him  with  the  toe  of  my  shoe;  the  blood  with  which  he  was 
distended  made  a  mark  on  the  smooth  concrete  floor  three- 
fourths  of  an  inch  in  length. 

The  two  notable  facts  of  this  migration  are; — 

1.  Cimex  was  definitely  migrating  from  sick  to  well. 

2.  This  migration  wras  taking  place  in  midwinter. 

If  the  premise  is  granted  that  cimex  may  be  the  agency 
of  transmission  of  poliomyelitis,  we  would  expect  to  find 
the  disease  endemic  in  certain  houses.  Wickmann  noted 
such  apparent  endemicity,  and  reported  it  as  proof  of  the 
contagious  nature  of  poliomyelitis:— 

The  disease  was  not  generally  spread  through  the  city  (Stock- 
holm), but  was  particularly  localized  in  certain  parts,  so  that  in 
neighboring  houses  groups  of  cases  of  3,  5,  or  7  occurred.  In  one 
instance  there  occurred  a  case  in  one  dwelling  house  from  which  the 
family  removed  on  October  ist.  A  second  case  developed  in  this 


ETIOLOGY   OR   CAUSE   OF    IXFAXTILE    PARALYSIS.         63 

same  house  not  long  after  the  entrance  of  the  family  that  moved  into 
the  rooms  vacated  by  the  first  family.     (\Yickmann.) 

If  cimex  proves  to  be  the  usual  agent  in  the  trans- 
mission of  poliomyelitis,  there  will  be  explained  the  reason 
for  non-development  of  secondary  cases  of  the  disease  in 
the  well-ordered  hospital  or  ward.  The  modern  hospital, 
with  fumigation  and  removal  of  patients'  clothing,  and 
frequent  fumigation  of  wards  and  rooms,  does  not  harbor 
this  pest.  The  unclean  hospital  ward  which  harbored 
cimex  might,  then,  be  responsible  for  secondary  cases  oc- 
curring in  institutions. 

Cases  of  poliomyelitis  which  develop  during  confine- 
ment in  a  jail  (Harbitz,  of  Norway;  Manning),  and 
secondary  cases  occurring  in  institutions  (Tewksbury, 
Sheppard),  and  also  cases  developing  in  a  hospital  (Har- 
bitz) strongly  suggest  that  transmission  of  the  disease 
and  inoculation  have  been  produced  by  a  blood-sucking 
insect.  If  these  institutions  are  not  subjected  to  a  semi- 
annual fumigation,  the  possibility  is  at  once  aligned  in  the 
class  of  probabilities.  As  we  have  seen,  the  bedbug  is  the 
insect  adapted  by  habits  of  concealment,  and  feeding,  to 
be  the  guilty  part}-. 

Experimental  transmission  of  acute  poliomyelitis  by 
the  agency  of  the  bedbug,  from  a  poliomyelitic  monkey  to 
a  healthy  monkey  which  became  paralyzed  and  subse- 
quently died,  was  reported  in  December,  1912,  by  Howard 
and  Clark,  of  Rockefeller  Institute.  The  organism  re- 
mained active  seven  days  after  feeding.  Bedbugs  are 
extremely  resistant  to  destructive  measures,  and  the 
human  being  has  but  a  single  layer  of  epithelium  for  pro- 
tection from  the  inoculation  of  disease  which  may  follow 
their  bite.  That  bedbugs  may  transmit  acute  poliomyelitis 
has  been  demonstrated;  they  may  prove  to  be  the  usual 
and  common  carriers  of  the  disease  from  man  to  man. 


64  INFANTILE   PARALYSIS. 

CONTACT  TRANSMISSION  OF  ACUTE 
POLIOMYELITIS. 

The  theory  of  contact  transmission  of  poliomyelitis 
through  secretions  from  the  mouth  and  nose,  which  was 
advocated  by  Flexner,  has  had  wide  acceptation  by  the 
public,  and,  unfortunately,  from  patent  medicine  vendors, 
who  have  advertised  and  distributed,  gratis,  samples  of 
"cures"  for  infantile  paralysis,  with  a  formula  based  on 
nasal  antisepsis. 

Many  investigators  have  proved  that  the  nasal  and 
buccal  secretions  of  the  acute  case,  and  the  mucous  mem- 
brane removed  from  these  areas  after  the  death  of  the 
subject,  will  transmit  the  disease  when  inoculated  into 
the  normal  monkey. 

Osgood  and  Lucas  were  able  to  transmit  the  disease 
from  the  tonsils  and  adenoid  tissues  of  monkeys  as  late 
as  five  months  and  a  half  after  the  attack  was  over.  They 
were  also  able  to  transmit  the  disease  from  the  naso- 
pharyngeal  mucosa  of  a  monkey  that  had  been  kept  alive 
by  careful  nursing,  and  found  the  germs  present  at  the  end 
of  five  and  a  half  months.  They  obtained  the  tonsils  and 
adenoid  tissue  removed  from  a  little  girl  six  months  and 
ten  days  after  having  had  a  spastic  paralysis  from  this 
disease.  The  preparation  from  these  was  injected  in 
various  amounts  into  three  monkeys.  One  of  these 
animals  developed  typical  signs  of  the  disease  accompanied 
with  paralysis. 

Kling  and  Petterson  demonstrated  the  presence  of 
the  active  virus  in  the  secretions  of  the  mouth,  the  nose, 
the  trachea,  and  in  the  intestines  after  death  from  this 
disease.  They  also  have  found  it  in  the  mouth  and 
pharynx  and  in  the  intestinal  canal  of  patients  during  life. 
They  obtained  the  secretions  of  the  mouth  and  pharynx 


ETIOLOGY   OR   CAUSE   OF    INFANTILE    PARALYSIS.         65 

by  thorough  rinsing  with  a  syringe.  The  intestinal  mucus 
was  obtained  after  evacuating  the  intestines  by  means  of 
an  enema,  and  then  thoroughly  washing  out  the  sigmoid 
with  salt  solution.  The  fluids  thus  obtained  were  filtered 
and  injected  into  the  peritoneal  cavity  and  into  the  sciatic 
nerves  of  monkeys.  In  all,  13  patients  were  examined 
and  the  presence  of  the  virus  demonstrated  in  u  by  the 
production  of  typical  paralysis  in  the  monkeys. 

Transmission  by  means  of  the  nasal,  buccal,  and 
pharyngeal  secretions  when  an  inoculation  atrium  is 
present  may  not  be  of  frequent  occurrence,  for  Rosenau. 
Sheppard,  and  Amoss  wholly  failed  in  producing  such 
transmission  in  a  series  of  18  cases.  (Boston  Medical  and 
Surgical  Journal,  May  25,  1911.) 

As  we  have  previously  stated,  there  seems  to  be  reason- 
able doubt  that  transmission  has  been  experimentally  pro- 
duced when  a  solution  of  continuity  and  therefore  an 
inoculation  wound  could  be  absolutely  ruled  out,  and  yet 
the  presence  of  active  virus  in  or  on  the  mucous  mem- 
branes must  receive  due  consideration  in  all  measures 
which  contemplate  the  prophylaxis  or  treatment  of  the 
disease. 

TRANSMISSION  OF  ACUTE  POLIOMYELITIS 
THROUGH  THE  DOG. 

Epidemic  paralysis  among  domestic  animals  has  been 
found  to  occur  coincidently  with  epidemic  poliomyelitis  by 
all  epidemiologists  of  the  disease.  The  subject  is  fully 
discussed  in  the  first  chapter  of  this  volume.  Paraly^i- 
of  horses,  dogs, 'and  cats  are  most  frequently  noted.  The 
association  between  master  and  brute  is  perhaps  most 
intimate  in  the  case  of  the  dog.  The  fact  that  the  mucous 
secretions  or  saliva  of  cases  of  acute  poliomyelitis  have 
been  shown  to  be  infective  has  a  strong  bearing  on  the 


66  INFANTILE    PARALYSIS. 

following  report  by  Lan^'lmrst.  of  Illinois,  on  the  apparent 
transmission  to  2  cases  of  acute  poliomyelitis  through  the 
dog:— 

Report  of  Cases. — Case  i.  The  patient,  aged  35,  was  a  man  of 
good  habits  and  athletic  build.  He  was  married  and  had  one  child. 
Previous  history  was  negative,  with  the  exception  of  what  I  shall 
mention  later.  He  was  taken  with  a  severe  cough  and  sore  throat 
about  one  week  before  paralytic  symptoms  appeared.  He  continued 
his  outdoor  work  of  driving  a  wagon,  which  was  arduous,  at  that 
time,  on  account  of  the  extreme  cold  and  snow.  The  symptoms 
developed  rapidly ;  he  felt  weak  in  his  limbs  one  afternoon,  and  that 
evening,  after  going  to  the  toilet,  he  was  unable  to  return  without 
assistance.  I  saw  him  a  few  hours  later  and  found  him  completely 
paralyzed.  He  was  gasping  for  breath  and  was  intensely  cyanosed  ; 
his  legs,  arms,  abdomen,  chest,  neck,  and  throat  were  paralyzed.  He 
spoke  with  great  effort  and  was  unable  to  swallow ;  his  eye  muscles 
were  intact  and  their  reflexes  were  normal.  All  of  his  other  reflexes 
were  absent ;  sensation  of  heat  and  cold  was  normal ;  only  slight  pain 
was  present  on  pressure  over  nerve-trunks;  he  could  locate  and 
differentiate  between  pin-pricks  with  the  sharp  and  the  blunt  end. 
The  sensorium  was  clear ;  the  patient  was  in  good  spirits  and  had  no 
sense  of  fear.  Loud  bubbling  rales  filled  his  chest  and  he  was  con- 
tinuously making  ineffectual  efforts  at  coughing,  to  try  to  bring  up 
the  mucus  that  was  choking  him.  His  vesical  and  rectal  sphincters 
were  tonic.  Pulse  was  130.  temperature  100°,  respiration  45. 

By  compressing  his  thorax,  and  by  fixing  the  diaphragm  (using 
pressure  over  upper  abdominal  region),  we  were  able  to  help  him  to 
'  expectorate  considerable  mucus  of  a  frothy  nature.  At  times  the 
respirations  were  so  labored  and  the  cyanosis  so  urgent  that  artificial 
respiration  was  resorted  to,  and  kept  up  for  hours  at  a  time.  Dr. 
Peter  Bassoe  saw  the  case,  in  consultation,  and  he  favored  the  diag- 
nosis of  acute  anterior  poliomyelitis,  but  also  considered  the  pos- 
sibility of  its  being  Landry's  paralysis.  On  account  of  the  increasing 
dyspnea,  Dr.  Richter,  who  had  been  using  an  improved  pulmotor 
(made  from  a  vacuum  cleaner),  was  called  in,  to  use  his  apparatus. 
This  was  used  with  good  results,  and  was  alternated  with  the 
Sylvester  method.  Atropine,  strychnine,  caffeine,  and  camphor  were 
used  hypodermically ;  normal  salt  solution  was  used  by  rectum,  by 
the  drop  method.  The  urine  contained  no  albumin,  and  the  examina- 


ETIOLOGY   OR   CAUSE   OF    I XI-. \XT1LE    PARALYSIS.         57 

tion  of  the  sputum  showed  many  leucocytes,  and,  among  other  pus 
organisms,  Pfeiffer's  bacillus.  After  the  third  day  the  patient  was 
able  to  move  his  hands  and  legs  slightly,  but  after  five  days  of  severe 
suffering  he  became  delirious,  and  on  the  sixth  day  died. 

From  the  history  I  learned  that  the  patient's  dog  had  been  >ick 
about  two  or  three  weeks  before,  and  was  unable  to  stand  on  its 
hind  legs.  The  patient  fed  the  dog  and  cared  for  him.  The  patient 
remembered  that  he  had  a  few  scratches  on  his  hand,  and  that  on 
one  or  two  occasions,  the  dog  licked  his  hand.  Flcxner  has  shown 
that  the  nasal  mucosa  is  one  of  the  points  of  egress  of  the  virus.  If 
the  dog  had  been  inoculated  with  the  virus  at  some  time  and  had  not 
immediately  contracted  the  disease,  he  may  have  been  a  carrier  and 
not  contracted  the  disease  until  his  vitality  was  lowered  by  living  in 
a  kennel  in  the  cold  weather.  The  dog  could  have  inoculated  his 
master  with  the  secretions  from  his  nose  and  mouth. 

Case  2.  The  patient,  a  boy  of  6  years,  was  brought  to  my  office 
Aug.  9,  1912,  to  be  treated  for  a  bite  inflicted  by  his  pet  dog.  I  saw 
him  about  an  hour  after  the  injury  and  applied  a  I  per  cent,  solution 
of  formaldehyde  and  then  used  tincture  of  iodine.  The  wound  healed 
nicely.  The  boy  then  accompanied  his  parents  on  a  trip  to  Canada, 
leaving  here  August  23(1.  \Yhile  in  Canada,  on  the  3Oth,  the  boy  had 
a  little  fever  and  complained  of  his  neck  being  stiff.  The  family 
immediately  returned  to  Elmhurst,  arriving  here  September  1st.  I 
-aw  the  boy  at  this  time;  he  had  a  slight  fever  (temperature  101°), 
and  did  not  complain  greatly.  He  had  pain  in  the  back  of  his  neck 
and  in  his  head,  and  he  felt  weak.  His  reflexes  were  present  and  he 
was  able  to  stand  and  walk.  \Yhen  I  saw  him  the  next  morning  he 
was  paralyzed  in  all  of  his  extremities ;  the  chest  and  neck  muscles 
were  also  involved.  The  reflexes  were  absent.  Dr.  Abt  saw  the 
patient  with  me  and  called  it  infantile  paralysis.  Dr.  D'Orsay  Hecht 
also  saw  him  a  few  weeks  later  and  agreed  to  the  diagnosis.  The 
hoy  is  gradually  recovering.  ("Possible  Transmission  of  Poliomye- 
litis Through  the  Dog,"  Langhorst,  Jour.  Amer.  Med.  Assoc.,  Dec. 
28,  1912.) 

Langhorst  considers  that  poliomyelitis  is  undoubtedly 
transmitted  to  man  through  more  than  one  intermediary, 
and  ])< »ints  out  that  the  biting  fly  which  attacks  animals 
may  transmit  the  infection  to  the  dog,  which  thereupon 
contracts  the  disease.  Langhorst's  contribution  is  of 


68  INFANTILE    PARALYSIS. 

great  interest  and  value,  not  only  that  it  demonstrates  a 
possible  new  carrier  of  epidemic  poliomyelitis  in  close  as- 
sociation with  and  therefore  a  direct  menace  to  man,  but 
also  that  this  report  is  a  new  link  in  the  chain  of  evidence 
slowly  forging  which  unites  poliomyelitis  and  rabies  in  a 
relationship  which  simulates  identity.  There  is  a  close 
analogy  between  these  two  diseases;  the  toxin  of  each  is 
widely  diffused  through  the  system,  and  localizes  in  a 
destructive  attack  on  the  central  axis ;  the  atrium  of  in- 
fection of  each,  so  far  as  has  been  shown,  is  through  a 
wound;  Proescher,  of  Pittsburg.  has  demonstrated  their 
close  biological  analogy,  and  now  Langhorst  has  followed 
with  the  report  of  the  transmission  of  a  paralytic  infection 
of  the  dog  to  the  human  adult,  who  developed  a  typical  case 
of  acute  poliomyelitis  of  the  ascending  paralytic  type,  with 
death  from  asphyxia  on  the  sixth  day.  The  world  of 
medicine  is  much  indebted  to  this  scientific  observer. 

To  summarize  the  foregoing,  the  present  status  of 
knowledge  of  the  method  and  agent  of  transmission  of 
acute  epidemic  poliomyelitis  is  that  :— 

Poliomyelitis  has  been  artificially  transmitted  to  mon- 
keys by : — 

(a)  Inoculation:  I.  With    poliomyelitic    tissue.       IT. 
With  poliomyelitic     secretions.      III.  With    comminuted 
bodies  of  bedbugs  which  had  previously  fed  on  infected 
monkeys.     IV.  By  the  bites  of  stable-flies  which  had  pre- 
viously fed  on  infected  monkeys. 

Poliomyelitis  has  been  spontaneously  produced  in  man 
by:- 

(b)  Inoculation :   I.  From  the  saliva  of  a  paralytic  dog. 
The  theory  of  transmission  of  acute  poliomyelitis  by 

contact  contagion  or  fomites  remains  unpmveii. 


CHAPTER   III. 

Predisposing  Causes. 

CERTAIN  factors  may  prove  active  in  causing  this  in- 
fection by:— 

(a)  Increasing  susceptibility  of  host. 

(b)  Facilitating  transmission  of  infection. 
(fc)   Increasing  virulence  of  infectious  virus. 

Race. — Xo  race  is  known  to  be  exempt  from  this  in- 
fection. The  white,  yellow,  brown  and  black  man  have  all 
been  included  in  reports  of  epidemics  of  the  past  five  years. 
It  is  true  that  from  those  reports  it  would  appear  the  white 
race  has  supplied  a  preponderating  number  of  victims.  As 
the  white  races  alone  publish  statistics  of  epidemic  visita- 
tions, we  have  little  means  of  knowing  what  other  races 
may  have  been  involved.  An  epidemic  in  the  Island  of 
Xauru  (which  is  situated  north  of  Australia  and  near  the 
equator)  attacked  470  natives  and  220  imported  laborers, 
of  whom  a  proportion  were  Chinese.  Of  the  80  white 
persons  included  in  a  total  population  of  2330,  only  3  were 
attacked. 

Geographic  Distribution. — The  great  majority  of  epi- 
demics of  infantile  paralysis  of  which  we  have  any  record 
occurred  in  the  temperate  zone.  X'orth  Europe,  the 
United  States,  and  Canada  were  most  affected.  Of  the 
European  countries,  Xorway  and  Sweden  have  had  re- 
peated epidemics  and  of  recent  years  very  extensive  ones. 
Germany,  Austro-Germany,  France,  Italy,  and  England 
have  had  more  or  less  severe  visitations,  and  there  is  little 
probability  that  other  European  countries  have  escaped, 
since  the  disease  became  pandemic  in  1908. 

(69) 


70  INFANTILE    PARALYSIS. 

In  the  Western  Hemisphere  epidemics  have  occurred 
from  Toronto  to  Cuba,  and  from  Boston  to  the  Golden 
Gate.  Florida,  in  the  semitropics,  and  Cuba,  in  the  tropics, 
were  visited. 

The  seacoast  of  Australia  has  suffered  from  a  number 
of  epidemics,  and  the  Island  of  Nauru,  north  of  Australia, 
was  swept  by  an  epidemic  in  January,  1910,  which  attacked 
30  per  cent,  of  the  inhabitants.  Nauru  is  in  the  equatorial 
belt.  It  is  also  geographically  isolated,  and  the  infection 
must  have  been  transported  to  the  island.  Is  it  probable 
that  Australia  and  Nauru,  alone  of  Oceanica,  were  in- 
fected ? 

Tubby  and  Jones,  of  Liverpool,  state  that  many  of  the 
children  brought  to  them  with  infantile  paralysis  had  been 
born  in  India  or  other,  tropical  countries,  and  had  passed 
the  first  three  years  of  their  lives  abroad,  and  add  that  the 
prevalence  of  the  disease  among  English  children  in  India 
is  remarkable. 

Hill,  of  Minnesota,  relates  information  from  a  British 
East  Indian  nurse  to  the  effect  that  poliomyelitis  is  very 
common  among  the  native  children  during  the  hot  weather, 
especially  at  the  end  of  the  dry  season;  to  which  he  adds 
the  comment  that  these  children  are  of  a  notoriously  1<>\\ 

~ 

nutritional  status,  and  acquire  the  disease  at  a  season 
notorious  for  intense,  overwhelming  heat,  dryness,  and 
dust.  I  would  add  to  the  comment  that  the  bedbug  is  an 
ever-present  pest  in  British  East  India,  and  the  high-caste 
native  will  not  destroy  nor  allow  destroyed  any  form  of 
animal  and  insect  life.  The  East  Indian  nurse  is  said  to 
have  stated  that  white  children,  belonging  chiefly  to  the 
families  of  officials,  better  nourished  and  usually  taken  to 
the  hills  during  the  hot  season,  seem  to  escape  the  infec- 
tion almost  entirely.  Dr.  Hill  states  that  the  literature 
consulted  makes  no  note  of  this. 


PREDISPOSING    CAUSES.  71 

A  personal  communication  from  Dr.  Hernaman- John- 
son, of  England,  states,  "I  have  noted  that  epidemic  palsy 
prevails  in  river  valleys  when  enteric  is  common." 

Age  Incidence. — There  is  a  wide  variation  in  the  re- 
ports of  investigators  regarding  the  age  most  liable  to 
be  affected,  which  is  shown  in  the  following  table  :— 


ARCS. 

Wiekmann, 
Sweden, 
1905- 

Manning, 
Wisconsin, 
1908. 

Lovett, 
Mass., 
1909. 

\\-\v  York 
City, 
1907. 

o  to  5  years. 
6  and  over. 

350   40.6% 

5iS  59495 

74  4<;^ 
-(.  50.2^ 

440  71-5% 
'75  28.5% 

660  90.5  c/( 
69      9-5% 

Total  number 

«.f  cases.  868  150  615  729 


A  wide  discrepancy  is  noted  in  the  first  figures  and  the 
last.  Sweden  reporting  5<).4  per  cent,  of  her  868  cases  as 
o  years  and  ahove:  while  Xew  York  City  reported  only 
9.5  per  cent,  of  ~2()  cases  as  over  6  years  of  age.  As 
XYickmann's  report  was  the  result  of  a  careful  survey  of 
the  entire  field  undertake;!  by  order  of  the  government,  it 
seems  probable  that  it  is  the  most  nearly  accurate.  A  large 
proportion  <>f  cases  among  young  adults,  and  fatal  cases 
of  adults,  in  America,  have  hitherto  remained  unreported, 
because  of  faulty  diagnosis. 

The  tables  of  age  incidence  of  this  disease  in  America 
will  be  modified  as  more  and  more  careful  records  are 
kept.  Xew  York  State,  in  reporting  the  227  cases  in 
the  State  for  10,10,  already  shows  a  striking  difference  in 
age-incidence  percentages,  128  of  the  cases,  or  56.4  per 
cent.,  being  4  years  of  age  or  under,  while  99,  or  43.6  per 
cent.,  were  5  years  old  or  above. 

In  regard  to  this  point  it  is  of  interest  to  note  the  re- 
port of  a  physician  practising  in  a  small  community.  The 


72  IXFAXTILE    PARALYSIS. 

man  at  work  in  a  village  or  hamlet  sees  every  case  in  that 
area.  I  am  inclined  to  regard  with  special  interest  such 
reports  from  a  careful  observer. 

Dr.  H.  Prill  reported  n  cases  from  Augusta  (popula- 
tion 1400),  Wis.,  1908:— 

2.  years  of  age.  ...      I 

5  "  -    ....      i 

6  '    .  .  .  .     2     1 8.1%  below  6  years  of  age. 

8  -  -  ....  i 

12  -  3 

23  -  "  i 

25  -  '  "  . . . .  i 

32      "  "    .  . .  .      i     8 1. 8%  above  6  years  of  age. 

Total    ii 

Dr.  P.  Riley  reported  13  cases  from  Elk  Mound  (  popu- 
lation 94),  Wis.  :— 

2  years  of  age ...     2 

5  "  "    .  .  .  .      i     23%  below  6  years  of  age. 

6  "  -    ....     2 

....  i 

9  "                 ....  i 
ii      '"           "  ....  3 
17      "            "  i 

19      "  "   .  . . .      i     76.9%  above  6  years. 

23      -  "   ....      i 

Total   13 

i  Personal  reports  to  writer.") 

These  groups  are  small,  but  suggest  that  we  labor 
under  some  misapprehension  in  believing  this  malady  to 
spend  its  maximum  force  on  small  children. 

(Sheppard.) 


PREDISPOSING    CAUSES. 


73 


Age. 

Cases. 

Deaths. 

Mortality 
(per  cent.). 

From  birth  to  12  months,  inclusive  . 
>    years    

117 
61 

II 
8 

9.40 
I  "?  1  1 

^    years    , 

08 

IO 

1O'1  L 

IO  2O 

4  years  

y-7 
60 

IO 

1  J.  -1Q 

^  years  . 

si 

2 

^  QO 

6-10  vears,  inclusive   

Ql 

7 

7  ^2 

1  1-20  years    inclusive   

60 

10  14 

^1-30  vears,  inclusive   

28 

c 

I/SO 

40  years  and  over   

l< 

2 

I-I.^-J 

Totals  

601 

62 

Average  mortality    

10.^1 

Period  of  Dentition. — It  would  seem  that  being  a  teeth- 
ing child,  i.e.,  a  growing  animal  in  a  period  of  acute  de- 
velopment, enormously  increases  susceptibility  to  any 
infection.  Poliomyelitis,  with  its  pathologic  affinity  for 
the  ganglionic  motor  cells,  finds  ready  victims  among  chil- 
dren whose  developmental  period  and  tremendous  activity 
render  these  areas  correspondingly  vascular.  Lessened 
resistance  due  to  the  rapid  growth  can  little  check  the 
toxic  organism,  and  the  child  often  succumbs  during 
the  stage  of  invasion,  before  the  formation  of  germicidal 
antibodies. 

.\dolesccnce. — This  period,  in  young  males,  is  appar- 
ently one  of  increased  susceptibility.  In  150  cases 
analyzed  in  the  \Yisconsin  epidemic,  19  were  boys  from 
ii  to  20  years  of  age. 

.  I  (hilts. — Xo  age  is  exempt.  Although  the  proportion 
of  cases  decreases  directly  in  each  decade  following  the 
first,  numerous  cases  are  reported  occurring  among  adults 
of  young,  middle,  and  advanced  age. 


74  JNFAXT1LF    I'AKALYSIS. 

$c.v. — That  males  are  vastly  more  liable  to  this  dis- 
ease is  shown  by  the  following  table  of  reports  of  epi- 
demics in  which  the  sex  affected  is  recorded  :— 

INCIDENCE  OF  SEX  IN  SIX  EPIDEMICS  OF  POLIOMYELITIS. 

Males.      Females.  Total. 
iS.,4  Caverly1  Vermont  53  34  $7 

1908  Manning1  Wisconsin  91  59  150 

1909  Lovett  Massachusetts         31)5         ji>3  628 
1909  Anderson1                Nebraska                   48           38  Si. 

1909  Hill1  Minnesota  193          [39  33.' 

1910  Dixon  Pennsylvania          437         33'  >  773 


Totals    1 187         869         2051 ) 

1  Vrcentage 57-7' <     42-3% 

Where  age  and  sex  have  been  reported  it  is  manifest 
that  the  disproportion  of  males  affected  increases  directly 
with  the  decade  of  ages.  From  i  to  10  years  of  age  the 
males  are  slightly  in  excess,  and  the  proportional  increase 
in  the  succeeding  decades  is  roughly  shown  in  the  follow- 
ing table  of  Wisconsin  cases  :— 

SEX  INCIDENCE  BY  DECADES. 

Males.  Females. 

o  to    9  years  inclusive  64  46 

10  to  19     "  16  10 

20  to  29     "  9 

30  to  39    ••  «  i  2 

40     "  i 

48     "  i 

91  59=150 

This  excess  of  males  has  been  commented  on  by  many 
of  the  writers  on  this  subject,  and  the  attention  of  the 
public  drawn  to  the  fact  by  the  outbreaks  at  two  notable 

1  Cases  reported  are  only  those  where  sex  was  stated. 


PREDISPOSING   CAUSES. 


75 


colleges  for  men,  as  well  as  the  several  thrashing  crews 
whose  members  were  simultaneously  attacked.  It  seems 
probable  that  many  sudden  deaths  among  adult  males 
since  this  disease  became  epidemic  in  America,  due  to  the 
bulbar  form  of  this  disease,  have  been  diagnosed  incor- 
rectly as  resulting  from  ptomaine  poisoning,  meningitis, 
lock-jaw,  and  apoplexy. 

OTHER  FACTORS  WHICH  MAY  INCREASE  SUS- 
CEPTIBILITY OF  HOST. 

Concomitant  conditions  more  or  less  constantly  present 
in  epidemics  were  formerly  regarded  as  direct  causes  of 
the  disease,  while  their  relationship  was  usually  that  of 
increasing  the  susceptibility  of  the  individual.  Trauma, 
overexertion,  and  exposure  are  often  given  as  causes  of 
an  attack  of  poliomyelitis,  while  their  true  relationship  is 
that  of  lessening  or  lowering  resistance,  and  in  the  cases 
of  a  stumble  or  fall  the  accident  belongs  properly  in  the 
list  of  prodromata  of  the  attack. 

Overexertion  is  frequently  given  as  a  factor  in  the 
illness,  especially  of  young  adult  males.  A  Dunn  County, 
Wisconsin,  farmer  told  of  an  extreme  nervous  irritability 
and  sense  of  impending  disaster  which  kept  him  in  the 
field  at  work  until  overcome  with  exhaustion.  He  knew 
the  grain  must  be  got  in,  and  never  worked  so  hard.  A 
farmer's  wife  ascribed,  the  illness  of  her  14-year-old 
daughter  to  working  in  the  hot  sun,  carrying  stones  from 
a  field.  Such  labor  during  the  onset  of  an  acute  disease 
would  directly  devitalize  and  lessen  resistance  of  the 
organism.  In  several  recorded  cases  exertion  developed 
an  arrested  form  of  the  disease,  provoking  a  late  paralysis 
and  death. 

Exposure  to  cold  and  dampness  seems  in  many  in- 
stances to  have  been  due  indirectly  to  the  effort  of  a 


76 


INFANTILE    PARALYSIS. 


fevered  child  to  get  to  water.  Swimming,  unduly  pro- 
longed, is  often  given.  The  high  fever  of  the  preparalytic 
stage  would  send  a  boy  directly  to  the  swimming  pool, 


Fig.  15. — Infantile  paralysis  in  Massachusetts. 
(Lovett  and  Richardson. ) 

especially  in  those  districts  where  bathtubs  are  a  luxury 
and  total  immersion  in  water  hard  to  come  at.  A  case  of 
so-called  exposure  was  found  to  be  that  of  a  12-year-old 


PREDISPOSING    CAUSES. 


77 


boy,  who  at  the  height  of  the  fever  crawled  under  a 
garden  hose  and  remained  for  hours. 

A  fall  is  often  given  as  the  cause  of  the  attack.  Such 
falls  are  undoubtedly  due  to  the  tremor,  inco-ordination. 
and  ataxia  that  precede,  and  may  be  called  the  aura  of 
the  onset.  In  yearlings  and  upward  to  5  or  6  years  of 
age  the  co-ordinating  centers  are  still  in  a  state  of  develop- 
ment and  delicate  adjustment,  which  a  slight  cause  will 
unbalance;  the  fall  is  the  result  and  not  the  cause  of  the 
lesion.  This  ataxia  may  profoundly  affect  the  strongest 
adult. 

Season. — The  epidemics  reach  their  maximum  during 
the  summer  months  of  that  area  in  which  they  are  mani- 
fest ;  in  the  Southern  Hemisphere  this  corresponds  to  our 
winter  months. 

Rainfall. — The  deficiency  in  rainfall  during  the  last 
eight  years  has  been,  of  course,  very  marked,  and  this 
factor  may  be  of  importance  in  the  spread  of  the  disease. 
It  certainly  has  to  be  taken  very  seriously  into  considera- 
tion if  we  accept  the  suggestion  of  Hill,  of  Minnesota, 
that  dust,  especially  dust  infected  with  horse-manure,  may 
be  responsible  for  the  transference  of  this  disease.  The 
deficiency  of  rainfall  in  Massachusetts  has  varied  since 
1904,  when  it  was  1.35  inches,  to  9.42  inches  in  1910. 
With  the  deficiency  of  rainfall  during  each  year  of  this 
period  has  occurred  a  sort  of  cumulative  effect,  which 
makes  this  deficiency  relatively  more  important  each  year. 
A  study  of  the  deficiency  rainfall  shows  that  the  largest 
number  of  cases  have  not  occurred  on  the  driest  years  in 
Massachusetts. 


78 


1  X FAX T I LE    PARALYSI S. 


DEF1C1EXCV    RA I XI- ALL    (1904-10). 


Year. 

Cases  in 
State. 

Actual 
(Inches). 

.Normal 
(Inches). 

Deficiency 
(Inches). 

IQO4   . 

42.81 

4C.i6 

—  I  3^ 

IQCK   . 

V7  60 

—  7.^6 

1906   

43  21 

—  I  QC, 

IOO7  . 

>?  i 

4/MO 

i-yo 
—  0.67 

1908  

u6 

77.6l 

.   —  7.CC 

IOOQ   • 

Q23 

42.IO 

—  3.06 

IQIO   . 

84  S 

T.Z  CQ 

—  0.42 

-3I-56 

(Lovett  and  Richardson.) 

FACTORS  INCREASING  VIRULENCE  OF  VIRUS. 

These  factors  are  unknown.  \Ye  know  that  in  the 
experimental  production  of  poliomyelitis  in  the  rhesus  ape, 
the  mortality  rate,  which  was  low  in  the  first  experiments, 
gradually  climbed  as  a  long  series  of  the  animals  were 
successively  injected  from  the  preceding  series,  until  the 
rate  became  100  per  cent.  This  would  indicate  that  the 
micro-organism,  obtained  post  mortem  from  a  child  victim, 
was  steadily  enhanced  in  virulence  by  culture  infra  Tit  am 
in  an  extremely  susceptible  host. 

Insanitary  conditions,  by  lowering  the  resistance  of 
the  individual,  might  contribute  directly  to  an  increased 
virulence.  Two  cases,  brothers,  both  fatal,  that  assumed 
an  appearance  simulating  septicemia,  w*ere  housed  in  the 
most  insanitary  environment  seen  during  the  Wisconsin 
epidemic.  The  house  was  built  on  made  ground,  in  a 
marshy  area.  The  well  and  privy  were  only  twenty-seven 
feet  apart,  and  other  hygiene  as  deplorable  as  possible. 

Time  in  epidemic,  late.  Numerous  reports  of  a  mor- 
tality rate  increasing  progressively  with  the  continuance 
of  the  epidemic  have  been  noted. 


CHAPTER   IV. 
Pathology. 


AN  AUTOPSY. 

THE  presence  at  autopsy  table,  in  the  case  of  an  ob- 
scure or  unknown  disease,  is  more  valuable  than  any  in- 
struction or  monograph.  There  may  be  many  physicians 
who  have  had  no  opportunity  for  conducting  or  attending 
such  an  autopsy.  It  is  so  delicate  a  matter  to  ask  grief- 
stricken  parents  to  allow  that  which  they  consider  mutila- 
tion of  their  beloved  dead,  the  physician  will  make  the 
request  only  when  he  is  assured,  first,  that  the  need  for  the 
public  weal  is  most  urgent,  and,  second,  that  the  examina- 
tion will  be  conducted  with  the  aid  of  every  modern  method 
of  research. 

In  the  recent  literature  of  poliomyelitis,  there  appeared 
a  graphic  report  of  an  autopsy  so  typical  and  instructive 
in  all  its  bearings  that  its  perusal  is  second  only  to  attend- 
ing an  autopsy  conducted  by  a  great  pathologist. 

The  case  is  typical  of  many  hundreds  occurring  in 
America  since  1906,  not  of  a  member  of  the  poor,  obscure, 
and  ill-nourished  classes,  but  from  that  class  of  the  well- 
to-do  and  luxurious  whose  homes  are  models  of  sanita- 
tion, and  whose  children  have  every  possible  physical 
advantage,  including  the  removal  from  probable  areas  of 
contagion  during  epidemics. 

It  is  to  be  noted  that  the  case  is  that  of  a  young  male, 
well  developed  for  his  age,  who  previous  to  the  onset  of 
this  disease  enjoyed  perfect  health.  The  case  was  reported 
by  Dr.  Colin  K.  Russell,  neurologist  to  the  Royal  Victorian 

(79) 


80  INFANTILE    PARALYSIS. 

Hospital,    in    the    Montreal    Medical    Journal    for    July, 


G.  E.,  a  well-developed  boy  of  10  years,  had  been  spending  the 
summer  with  his  parents  among  the  Laurentian  lakes,  and  previous 
to  the  onset  of  the  present  illness  enjoyed  perfect  health.  Early 
on  the  morning  of  August  5th  he  complained  of  headache,  and 
his  mother  noticed  his  breathing  was  more  rapid  than  usual.  He 
-pent  some  time  the  previous  day,  which  was  very  hot,  swimming, 
and  then  lying  out  on  the  roof  of  the  cottage  in  the  sun,  where 
there  was  a  little  breeze.  Just  before  sunset  he  and  some  friends 
paddled  some  considerable  distance  down  the  lake  ;  after  sunset  he 
did  not  paddle,  but  lay  in  the  bottom  of  the  boat.  He  was  scantily 
clad  in  the  light  clothes  he  had  worn  during  the  heat  of  the  day,  and 
on  being  questioned  said  that  his  feet  were  cold.  The  pain  in  his 
head  and  the  back  of  the  neck  continued  during  the  day  of  August 
5th.  His  temperature  was  100°  F.,  and  he  would  not  take  nourish- 
ment. 

The  following  day  he  developed  flaccid  paralysis  of  the  lower 
extremities,  with  loss  of  reflexes;  the  arms,  later  in  the  day,  also 
became  paralyzed,  especially  the  left.  Beyond  the  pain  in  the  head 
and  neck  he  did  not  suffer  and  his  mind  was  clear,  respirations  still 
very  rapid,  but  the  temperature  had  fallen  to  normal  and  he  took 
some  light  nourishment.  The  next  day  there  appeared  to  be  some 
improvement  in  the  arms,  but  otherwise  no  change  from  this  on. 
except  that  the  respirations  became  more  and  more  difficult.  When 
he  was  seen  by  Dr.  Eraser  Gurd  for  the  first  time  on  the  fifth  day 
of  the  disease  there  was  paralysis  of  the  intercostals  and  the  dia- 
phragm ;  life  \vas  dependent  on  the  extraordinary  muscles  of  respi- 
ration only,  and,  as  was  expected,  the  patient  died  that  night  of 
respiratory  failure. 

The  autopsy  was  performed  at  the  home  of  the  parents  ten 
hours  after  death.  The  brain  and  cord  were  removed,  the  other 
viscera  could  only  be  examined  in-  situ,  and  showed  no  abnormality. 
There  was  nothing  to  be  noted  about  the  calvarium,  the  dura  was  <>f 
normal  color  and  glistening;  there  was  no  congestion  either  over 
the  cord  or  brain. 

On  removal  the  brain  looked  large  for  the  size  of  the  head,  and 
it  weighed  1550  grams.  The  superficial  vessels  were  not  particularly 
engorged,  but  the  surface  of  the  brain  had  a  peculiar  slightly 


PATHOLOGY.  81 

bluish-gray  color;  on  section  the  edges  evert,  showing  the  capillaries 
of  the  cortex  someivhat  engorged  in  places. 

Cord. — The  dura  was  covered  posteriorly  with  a  thick  layer  of 
fat.  The  dura  itself  was  healthy  and  glistening.  On  palpation 
through  the  dura  the  cord  felt  extremely  hard,  especially  over  the 
lumbar  and  dorsal  regions.  On  opening  the  dura  the  vessels  of  the 
pia-arachnoid  were  slightly  congested.  The  whole  cord  from  the 
lower  end  of  the  cervical  enlargement  to  the  sacral  segments  has 
the  appearance  of  having  been  wound  carelessly  but  tightly  with 
fine  thread,  showing  everywhere  little,  irregular  ridges  and  bulges, 
evidently  the  swollen  cord  structure  bulging  through  the  strands 
of  the  pial  tissue.  There  was  some  slight  cloudiness  of  the  pia- 
arachnoid  over  the  posterior  surface.  On  section,  the  edges  evert 
to  a  marked  degree,  and  the  anterior-horn  region  looks  softened, 
swollen,  and  almost  diffluent;  that  is,  in  the  lumbar,  dorsal,  and  to 
a  less  degree  in  the  lower  cervical  region. 

Second  Sacral  Segment. — Microscopically,  there  is  infiltration 
of  the  meninges  with  round  cells  equally  well  marked  all  around  the 
cord.  This  infiltration  does  not  affect  the  nerve-roots.  The  super- 
ficial vessels  are  congested  and  surrounded  by  lymphocytic  exuda- 
tion ;  those  of  the  cord  substance  are  similarly  congested  and  show 
the  same  surrounding  round-celled  exudation.  The  infiltration  of  the 
gray  matter  is  also  present,  but  not  to  such  a  marked  extent  as  in 
the  previous  case.  Many  of  the  nerve-cells  have  disappeared,  'but  a 
few  still  remain  and  retain  their  normal  appearance.  The  con- 
gestion and  the  surrounding  exudation  are  quite  general,  affecting 
those  vessels  coming  in  from  the  periphery  of  the  cord  as  well  as 
the  branches  of  the  anterior  spinal  artery. 

Fourth  Lumbar  Segment. — The  same  picture  here;  slight 
meningitis,  marked  congestion  of  the  vessels  of  the  substance  of  the 
cord,  with  an  occasional  small  rupture  and  hemorrhagic  extrava- 
sation. The  same  perivascular  exudation  of  lymphocytes  and  round- 
celled  infiltration  of  the  gray  matter.  The  ganglion  cells  have 
entirely  disappeared. 

XintJi  Dorsal  Segment. — An  identical  appearance  to  those  al- 
ready described.  Only  a  few  nerve-cells  in  Clarke's  column  on  the 
left  side  remain. 

Eighth  Cervical  Segment. — The  infiltration  of  the  membranes 
is  less  marked  than  in  previous  sections.  It  is  present  to  the  greatest 
extent  in  the  anterior  fissures  and  follows  the  course  of  the  vessel 

6 


82  INFANTILE    PARALYSIS. 

into  the  left  anterior  horn ;  the  vessel  is  congested,  but  shows  no  evi- 
dence of  thrombosis.  The  congestion  of  the  vessels  in  the  substance 
of  the  cord  is  general,  but  the  perivascular,  round-celled  infiltration 
is  by  no  means  so  marked  as  in  the  previous  case,  nor  is  the 
infiltration  of  the  gray  matter  nearly  so  extreme.  None  of  the 
ganglion  cells  is  recognizable. 

Fifth  Cerrical  Scijmcnt. — Presents  an  almost  identical  picture 
to  that  just  described,  save  that  there  are  one  or  two  ganglion  cells 
still  recognizable  in  either  horn. 

Second  Cervical  Segment. — Presents  a  similar  appearance,  save 
that  the  round-celled  infiltration  is  again  more  marked,  especially 
around  the  vessels,  but  also  in  the  gray  matter. 

Lower  Medulla. — The  meningeal  infiltration  is  here  present, 
and  there  is  marked  generalized  perivascular  lymphocytic  exuda- 
tion. The  nerve-cells,  however,  appear  quite  normal. 

Right  Postcentral  Convolution. — Marked  congestion  of  the 
vessels  of  the  meninges,  with  surrounding  exudation  of  the  lympho- 
cytes ;  the  meninges  show  a  slight  degree  of  infiltration ;  the  cortex 
appears  quite  normal. 

Right  Olfactory  Lobe. — Nothing  abnormal,  although  the  vessels 
of  the  meninges  are  congested  and  show  the  usual  lymphocytic  exu- 
dation. The  posterior  ganglia  were,  unfortunately,  not  examined. 

PATHOLOGIC  ANATOMY. 

ACUTE  ANTERIOR  POLIOMYELITIS  results  from  an  in- 
fection with  a  specific  micro-Organism,  which  causes  a 
systemic  toxemia  and  localizes  in  a  destructive  attack  on 
the  cerebrospinal  axis,  the  lymphatic  system,  and  the 
parenchymatous  organs. 

Fatal  cases  of  acute  poliomyelitis  demonstrate  an  in- 
flammation of  not  only  the  gray  matter  of  the  cord,  1ml 
also  of  the  .whole  cord  and  pia,  the  medulla,  pons,  central 
ganglia,  and  the  cortex  of  the  brain,  always  in  connection 
with  a  like  inflammation  of  the  pia  mater.  It  might  be 
expected  that  in  mild  cases  with  symptoms  relating  only 
to  spinal  localization  the  inflammation  would  lie  limit t-d 
to  the  cord,  but  Wickmann,  by  autopsies  on  4  such  mild 


PATHOLOGY.  83 

cases,  "where  death  occurred  during  convalescence," 
found  evidence  of  the  process  throughout  the  whole 
nervous  system. 

The  lesions  of  the  central  nervous  system  invariably 
begin  in  the  delicate  and  highly  vascular  pia  mater,  and 
ramify  throughout  its  numerous  infoldings  into  the  fis- 
sures of  cord  and  brain.  The  process  involves  progres- 
sively the  lymph-spaces  of  the  covering  of  the  entire  cord, 
and  the  invasion  continues  by  way  of  the  lymph-spaces  of 
the  vessel  sheaths  as  they  penetrate  the  cord.  These 
vessels,  on  cross-section,  showr  a  girdle  of  round  cells. 
The  numerous  round  cells  crowding  the  pial  lymph- 
channels  and  perivascular  spaces  now  proliferate  in  the 
tissue  spaces  of  the  cord.  A  few  leucocytes  are  seen 
during  the  early  stage  of  this  process.  They  disappear,  to 
be  replaced  by  lymphocytes  and  proliferating  endothelial 
and  glial  cells,  which,  later  still,  are  found  in  company 
with  extravasated  red  blood-cells.  Capillary  congestion, 
stasis,  and  hyperosmosis  take  place,  followed  by  degenera- 
tion of  the  vessel  walls  and  minute  hemorrhagic  ex- 
travasation. Stasis  edema  and  compression  result  in 
degeneration  of  the  interstitial  tissue,  and  softening, 
vacuolization,  and  final  demolition  of  the  ganglionic 
neuron. 

The  inflammation  in  the  gray  matter  of  the  cord  cor- 
responds to  the  inflammation  of  the  pia  mater  of  the  same 
level.  No  isolated  foci  are  found  in  the  cord,  the  lesion  in 
the  gray  matter  being  invariably  an  extension  by  continuity 
from  affected  blood-vessel  sheaths  which  have  traversed 
an  infected  pia  mater.  There  may,  however,  be  an  in- 
filtration of  the  pia-arachnoid  and  its  vessel  sheaths  ex- 
tending perceptibly  into  the  cord,  with  no  invasion  of  the 
mvelin  tissue.  This,  as  \Yickmann,  the  observer,  points 
out,  is  one  of  the  conclusive  proofs  that  the  process  has 


84  1NTAXTILE    PARALYSIS. 

its  initiative  in  the  vascular  pia  mater,  following  which 
"flic  inffammation  thereupon  penetrates  the  substance  of 
the  cord  secondarily  along  the  vessels  to  reach  its  greatest 
intensity  in  the  cord  substance." 

The  misconceptions  which  arose  in  the  early  study  of 
the  pathology  of  this  disease,  were  due  to  the  fact  that  the 
autopsy  material  examined  was  usually  secured  from  a 
case  of  long  standing,  dead  from  some  intercurrent  dis- 
order, and  the  destruction  and  disappearance  of  the 
anterior-horn  motor  cells,  together  with  subsequent  cica- 
trization and  distortion  of  the  cord,  were  reasonably  sup- 
posed to  be  the  primary  lesion. 

MENINGES  OF  BRAIN  AND  CORD. 

Dura. — The  earliest  changes  in  the  cerebrospinal  axis 
take  place  in  the  meninges.  After  invasion  of  the  pia- 
arachnoid,  the  virus,  traversing  its  prolongations  and  in- 
foldings,  penetrates  the  nervous  tissue  of  cord  and  brain. 

The  dura  mater  is  usually  normal  in  appearance  and 
color,  and  not  congested.  It  is  usually  free  from  adhesions. 
In  a  healthy  young  male  dying  in  the  acute  stage,  it  was 
found  to  be  normal  in  appearance,  glistening,  and  the 
dura  of  cord  imbedded  posteriorly  in  fatty  tissue.  A 
dura  adherent  to  vertex  is  reported  at  autopsy  of  a  male, 
24  years  of  age,  dead  on  eighth  day  of  illness  from  respira- 
tory failure. 

The  dura,  much  thickened  and  closely  adherent  to  the 
pia-arachnoid  from  the  seventh  thoracic  segment  to  the 
first  lumbar,  completely  occluding  all  communication  for 
fluid  from  the  cord  or  encephalon  above  this  point,  was 
observed  in  the  autopsy  of  a  girl  of  13,  dying  in  the  fourth 
month  succeeding  a  complete  paralysis  of  all  skeletal 
muscles  below  the  waist  line. 


PATHOLOGY.  85 

Pia-arachnoid. — The  inner  membranes  of  cord  and 
brain  show  a  pronounced  vascular  infiltration  in  all  cases 
dying  during  the  acute  stage.  It  is  probable  that,  in  the 
mildest  of  ambulant  or  so-called  abortive  cases,  there  is 
in  the  stage  of  onset  an  edema  and  lymphocytic  infiltra- 
tion of  these  delicate  structures.  The  extent  of  the  in- 
filtration is  proportionate  to  the  vascularity  of  the  area, 
and  is  more  intense  on  the  anterior  surfaces  of  the  cord 
where  the  pia  accompanies  and  incloses  the  anterior  spinal 
vessels,  both  arteries  and  veins,  in  the  anterior  fissure. 
It  has  been  noticed  as  extreme  in  the  fonnatio  reflations. 
The  meningitic  inflammation  involves  the  pia-arachnoid. 
which  extends  to  and  infolds  the  posterior  root  fibers  and 
spinal  ganglia. 

This  infiltration  is  found  to  be  most  abundant  in  the 
sacral  and  himbar  regions  of  the  cord,  not  so  evident  in 
the  dorsal  region,  and  again  more  marked  in  the  cervical 
region.  The  blood-supply  in  these  portions  of  the  cord  is 
proportionate  to  the  motivation  of  the  corresponding 
musculature.  The  enormous  muscle  mass  of  hips  and  legs 
has  its  innervation  from  lumbar  and  lumbosacral  levels. 
The  musculature  of  torso  is  much  lessened  in  actual  bulk, 
as  well  as  activity  of  movement.  The  centers  for  innerva- 
tion of  the  shoulders,  arms,  and  hands  again  call  for  an 
increased  compensatory  nutrition.  Other  pertinent  factors 
would  include  (a}  the  ceaseless  activity  of  the  young  child 
and  adolescent  male,  and  (fr)  the  period  of  growth  of 
musculature. 

These  two  last-mentioned  conditions  would  combine 
to  increase  the  determination  of  blood  to,  and  perhaps 
lessen  resistance  of,  the  motivating  cell  for  which  the  virus 
of  poliomyelitis  appears  to  have  a  pathologic  affinity. 

AYhen,  on  sectioning  the  meninges,  the  swollen  and 
edematous  cord  is  exposed,  transverse  fibers  of  pial  tissue 


86  INFANTILE    PARALYSIS. 

are  seen  to  divide  the  surface  of  the  cord  into  many  irreg- 
ular crosswise  ridges,  as  if  the  cord  from  the  cervical 
enlargement  to  the  sacral  segments  had  been  snugly  wound 
with  fine  thread. 

The  same  evidences  of  meningitis  serosa  are  found  in 
the  pia-arachnoid  as  it  extends  over,  and  penetrates  the 
infoldings  of,  the  medulla,  pons,  and  cerebellar  and  cere- 
bral cortex.  This  inflammatory  condition  decreases  in 
degree  as  the  vertex  is  approached.  It  is  evidenced  macro- 
scopically  by  an  intense  hyperemia  of  the  vessels  and  tis- 
sues of  the  pia  covering  the  base,  and  the  central  lobe  of 
the  little  brain,  and  entering  the  Sylvian  fissure.  In  cases 
exhibiting  bulbar  symptoms,  an  edema  of  the  base  of  the 
fourth  ventricle  accompanies  this  hyperemic  congestion. 

CEREBROSPINAL  FLUID. 

The  virus  of  poliomyelitis  has  been  demonstrated  to  be 
present  in  the  cerebrospinal  fluid  of  monkeys  during  the 
preparalytic  stage.  As  its  presence  has  not  been  deter- 
mined in  the  spinal  fluid  of  man  or  monkey  after  the  paral- 
ysis has  occurred,  it  is  supposed  to  have  passed  into  the 
cord.  It  is  possible  that  under  certain  conditions  its  life 
cycle  is  self-limited. 

With  the  onset  of  the  disease  the  spinal  fluid  is  obtained 
under  slight  plus  pressure,  indicating  an  increase  in  the 
quantity  of  the  fluid.  With  a  violent  onset  with  marked 
meningism  the  pressure  may  increase  to  an  extreme 
degree,  and  the  fluid  will  spurt  with  considerable  force 
when  the  spinal  canal  is  tapped.  The  normal  pressure 
flow  is  drop  by  drop,  with  the  drops  moderately  slow  in 
forming. 

The  spinal  fluid  is  clear  at  onset,  becoming  opalescent 
in  the  preparalytic  stage,  and  entirely  clear  as  paralysis 


hi'.!*j     •  .  -f^V^    .'*'+•  ",  •  >'      -*,?*.'. 

' 


1 


1 


AJF    '         v  •  •>:.•-,-  >  -  x  ,*• 

i  » -• :  jj 

wKJ       ISii 

ry^x  *  '.  '  '.     '  .      -v    .    .  ;_,  •_. 


Fig.  16. — Acute  poliomyelitis  of  spinal  cord  (human).  Meningeal 
and  perivascular  infiltration.  (Skoog,  Bulletin  of  Kansas  State  Board 
of  Health.) 


m 


t     , 
t 


Fig.  17. — Inflammatory  process  extending  throughout  anterior  horn. 


Fig.  18. — Electrocardiogram  of  arrhythmia  regularly  seen  in  fatal 
cases.     (Peabody,  Draper,  and  Doches.) 


Fig.  19. — Diffuse  areas  of  hemorrhage  in  the  gray  matter  of  the 
cord.     (After  Peabody,  Draper,  and  Doches.) 


- 
- 

•:-    '       r- •;;•;, 


^fe^ 


t* 

• 

'   •  •  •  •    I 

,'  ; 

.     •  • 

.'•-•'.       •.          '„          .        .  •  •  .   .      •  •  ' 

20. — First  sacral  segment,  showing  infiltration  of  mononuclear  cells 
in  the  pia  mater  at  anterior  fissure  and  in  the  sheath  of  vessels. 


•    '     '  '     •'•'    '       \--r.y-     f'.TiS 

f"n^'-L<-'"  /  . 

^^ti^M 


j.  21. — Showing  the  intense  infiltration  of  mononuclear  cells 
around  the  anterior  spinal  vessels,  both  in  its  walls  and  in  the  adjacent 
gray  matter  of  the  anterior  horn.  This  vessel  is  a  continuation  of  that 
shown  in  Fig.  20. 

(From  Report  of  the  New  York  Committee.) 


Fig.  22. — First  sacral  segment,  showing  the  intense  infiltration  of 
mononuclear  cells  in  the  pia  mater.  (Epidemic  of  1907.)  (From 
Report  of  the  New  York  Committee.) 


PATHOLOGY.  87 

ensues.  This  preparalytic  opalescence  is  a  diagnostic  and 
prognostic  point,  confirmed  by  Frizzell. 

The  slight  milkiness  is  due  to  an  early  phagocytosis, 
of  which  a  few  white  cells,  at  first  polymorphonuclears 
and  then  lymphocytes,  are  manifested  in  the  fluid. 

There  is  an  increase  in  the  proteid  content  of  the  fluid, 
and  the  fluid  may  coagulate  spontaneously,  due  to  an  in- 
crease in  the  fibrin. 

THE  CORD. 

Palpation  of  the  cord,  before  the  dura  is  incised,  dis- 
closes its  extremely  hyperemic  and  edematous  condition. 
Resistance  to  pressure  is  increased,  and  in  rapidly  fatal 
cases  the  cervical  and  lumbar  portions  of  the  palpated 
cord  may  feel  hard  as  a  lead-pencil. 

On  incising  the  dura  the  cord  will  be  seen  to  present 
many  delicate  constricting  bands  of  pial  tissue,  between 
which  the  swollen  and  edematous  myelin  structure  of  the 
cord  is  elevated  in  transverse  ridges. 

On  section  of  the  cord  the  cut  edges  evert,  and  an 
unusual  surface  moisture  is  apparent,  due  to  edema. 
Small  hemorrhagic  areas  are  seen  by  the  naked  eye,  and 
the  motor  columns  may  show  evidences  of  softening. 

Microscopically,  the  early  changes  in  the  cord  consist 
of  a  hyperemia,  intra-  and  extra-  vesicular ;  a  perivascular 
infiltration  similar  to  and  continuous  with  that  of  the  pia 
mater ;  a  round-celled  infiltration  seen  as  a  collar  about  the 
cut  vessel  walls;  nere  and  there  foci  of  cells  heaped  to- 
gether, and  a  general  diffuse  infiltration  throughout  the 
myelin  tissue,  gray  and  white.  Hemorrhagic  areas  occur 
more  frequently  in  the  gray  nervous  tissue.  The  gray 
matter  in  general  is  more  affected  than  the  white,  although 
no  part  of  the  cord  at  cervical  and  lumbar  levels  escapes 
scot  free.  In  direct  proportion  to  the  vascular  supply  the 


88  INFANTILE    PARALYSIS. 

dilatation  and  engorgement  of  the  vessels  and  attendant 
infiltration  of  myelin  are  more  marked  in  the  anterior  horns 
than  the  posterior,  and,  at  the  high  levels  of  function,  the 
cervical  and  lumbar  areas  than  elsewhere.  The  anterior 
spinal  veins  are  as  much  congested  as  the  anterior  spinal 


Anterior  Portion  of  Cord 


Fig.  23. — Spinal  cord  with  acute  spinal  paralysis  forty-three  years 
after  beginning  of  disease,  a,  section  through  lumbar  (back)  enlarge- 
ment; b,  section  through  cervical  (neck)  enlargement.  (After  Char- 
cot  and  Joffroy.)  13,  23,  30,  36,  and  43,  localization  of  diseased  area 
in  anterior  horns  of  lumbar  enlargement  of  cord  in  child  2  years  old. 
eleven  months  after  beginning  of  disease.  (After  Roth.) 

t 

arteries,  and  some  observers  have  found  them  to  be  more 
involved. 

Hemorrhages  are  due  to  the  action  of  the  virus  on  the 
vessel  walls. 

The  secondary  effect  of  this  inflammatory  process  is 
the  damage  or  destruction  of  the  motor  ganglion  cell  of 


PATHOLOGY. 


89 


the  gray  matter.  The  vascular  infiltration  and  pressure 
edema  may  temporarily  inhibit  the  functioning  of  the  cell, 
with  a  resulting  regressive  paralysis.  When  more  ex- 
tensive damage  occurs  to  the  ganglion  cell  it  may  degen- 
erate and  disappear,  its  place  being  taken  by  young  glia 


1  iy.  24. — Blood  extravasation  into  the  motor  area  of  the  spinal  cord. 

cells.  Xn  ganglion  cell  is  immune,  although  the  cells  of 
Clarke's  column  are  relatively  immunized  by  their  distance 
from  the  seat  of  war,  and  often  escape  involvement.  The 
ganglion  cell  may  suffer  marked  impairment  in  function 
before  any  morphologic  change  can  be  determined.  Resti- 
tution of  necrosed  ganglion  cells  does  not  take  place,  but 
the  less  affected  cells  regenerate  and  regain  their  original 
function. 


90 


] XI-  \\TILE    PARALYSIS. 


The  changes  taking  place  in  a  degenerating  ganglion 
cell  include  cellular  invasion,  displacement  of  the  nucleus, 
vacuolization,  disintegration  of  the  nucleus,  tigrolysis, 
destruction  of  the  protoplasmic  processes,  and  necrosis. 
The  axon  is  the  last  part  of  the  cell  to  yield  to  the  destruc- 


/A 


Fig.  25. — General  view  of  human  cord  (cervical  level)  in  poliomyelitis. 

live  process,  which  accords  with  the  observed  fact  that  no 
degeneration  of  the  distal  nerve-fibers  has  been  determined. 
Destruction  of  the  ganglion  cells  always  takes  place  in  an 
area  suffering  from  a  furious  invasion;  the  destruction 
may  proceed  rapidly  over  large  areas,  but  in  each  area 
there  may  remain  apparently  normal  cells. 

The  invading  cells,  or  neuronophages,  which  gather 


PATHOLOCY. 


91 


in  the  vicinity  to  participate  in  the  destruction  of  the 
doomed  cells,  are  lymphocytes  and  polynuclear  cells  of 
probably  glial  origin.  The  absence  of  granules  from  the 
protoplasm  of  the  polynuclear  cell  demonstrates  their 
origin  to  be  other  than  leucocytic.  The  glial  parentage  of 


Fig.  26. — Perivascular  small  round-cell  infiltration. 

these  cells  is  made  probable  by  the  later  pathology  of  the 
cord  in  old  cases;  the  cord  is  seen  to  be  distorted,  the 
anterior  horn  or  horns  replaced  by  a  deformitive  glial 
tissue,  the  connective  tissue  of  the  nervous  system. 

The  areas  most  affected  in  the  cord  are  the  lumbosacral 
and  cervical  enlargements.  In  the  cervical  region  the 
damage  is  most  marked  in  the  anterior  horns,  although 
Clarke's  column  may  be  involved.  In  the  lumbar  enlarge- 


92 


INTAXT1LE    PARALYSIS. 


incnt  the  destruction  of  the  posterior  gray  columns  may  be 
as  extensive  as  that  of  the  cells  of  the  anterior  columns. 

An  invasion  of  the  white  matter  of  the  cord  appears  to 
be  a  tertiary  involvement ;  some  infiltration  of  the  vessel 
walls  and  an  edema  are  necessarily  constant  attendants  of 


Hind-celled  infiltratif 


SHE; 

hemorrhagic  areas. 


the  ferocious  attack  on  ihe  adjacent  gray  columns;  if,  how- 
ever, round-celled  infiltration  and  hemorrhagic  areas  are 
markedly  present  in  the  white  substance  of  the  cord,  there 
will  have  been  a  corresponding  clinical  history  of.  inco- 
ordination,  ataxia,  spasticity,  and  continued  exaggeration 
of  reflexes. 

Anterior    Root   Fibers. — Early    degeneration    of    the 
nerve-fibers  from  the  anterior  roots  has  been  observed  by 


PATHOLOGY.  93 

Robertson,  of  Minnesota.  Involvement  of  the  trophic 
branches  would  explain  the  numerous  cases  of  herpes 
zoster  among  elder!}-,  undernourished  women. 

Posterior  Root  Fibers  and  Spinal  Ganglia. — The  mem- 
brane covering  the  posterior  root  fibers,  on  their  emerg- 
ence and  continuing  over  the  spinal  ganglia,  shows 
vascular  congestion  and  infiltration  continuous  with  the 
meninges  of  the  cord.  Spinal  ganglia  diffusely  infiltrated 
with  round  cells  and  edematous  are  found.  More  advanced 
lesions  show  necrosis  of  the  nerve-cell  and  disintegration 
by  neurophages.  This  involvement  of  sensory  root  ganglia 
explains  the  intense  pain  of  the  preparalytic  stage. 

Peripheral  Xcrrcs. — The  pathology  of  the  peripheral 
nerves  and  their  termini  has  not  yet  been  worked  out. 
Cases  simulating  acute  multiple  neuritis  are  supposed  to 
be  due  to  lesions  in  the  cord.  This  is  yet  unproven. 

Medulla  and  Pons. — The  pathology  of  the  brain-stem 
gathers  tremendous  significance  from  the  fact  that  a 
majority  of  the  deaths  (90  per  cent.)  in  this  disease  are 
due  to  bulbar  paralysis.  Involvement  of  the  vital  centers 
in  the  medulla  leads  swiftly  to  paralysis  of  respiration  or 
cardiac  failure. 

An  intense  hyperemia  and  cell  infiltration  are  found 
throughout  the  medulla  and  pons,  extending  upward  from 
the  cord.  This  lessens  in  degree  at  the  higher  levels,  but 
is  never  absent  from  gray  matter  of  the  medulla  in  all 
cases  that  have  come  to  autopsy.  The  hyperemia,  which 
is  constantly  contiguous  to  congested  vessels  of  the  pia, 
may  lie  hemorrhagic.  An  edematous  condition  of  the  tis- 
sues making  up  the  floor  of  the  fourth  ventricle  is  found 
in  cases  presenting  serious  medullary  symptoms. 

The  motor  cells  of  the  cord  have  their  analogue  in  the 
cells  of  the  motor  nuclei  of  the  cranial  nerves.  Infiltration 
around  these  cells  induces  the  various  regressive  cranial- 


94  INFANTILE    PARALYSIS. 

nerve  paralyses.  In  rare  cases  nuclear  centers  are  more 
or  less  completely  destroyed;  usually  the  ganglion  cells 
are  damaged  or  destroyed  in  small  and  separate  areas  only. 

The  autonomous  centers  in  the  floor  of  the  fourth 
ventricle  whose  exact  locale  is  yet  uncertain,  which  play 
so  large  a  part  in  the  mechanism  and  governing  of  the 
body,  are  all  subject  to  the  most  extreme  disorder  from 
this  invasion. 

The  vagus  center  registers  its  first  irritation  with 
tachycardia,  or  arrhythmia,  or  both.  The  tachycardia  is 
usually  extreme.  There  are  undoubted  cases  where  the 
paralysis  of  the  heart  precedes  the  respiratory  paralysis. 

Celestine  M.,  male,  13;  paralysis  of  flexors  and  extensors  of 
both  legs.  Died  sixty  hours  after  onset  of  heart-failure.  Medulla 
involved.  Respiration  unaffected.  (Personal  report  from  Dr. 
Boothby,  Hammond,  Wisconsin.) 

The  excessive  sweating,  which  attends  the  fever  in 
some  cases,  implies  an  involvement  of  the  vasomotor 
centers.  The  uncontrollable  projectile  vomiting  is  also 
induced  by  irritation  at  the  centers.  The  heat  centers  may 
be  profoundly  affected. 

Elbe  F.,  1 8  months.  Acute  onset  May  26,  1908.  Partial 
paralysis  of  both  arms  and  both  legs.  Left  facial  paralysis.  Con- 
vergent strabismus  of  left  eye.  Unable  to  hold  head  erect.  Motion 
returned  to  arms  on  twelfth  and  limbs  on  fourteenth  day.  Eighteenth 
day,  hypoglossal  involvement.  Twenty-fourth  day,  twitching  of 
arms  and  legs.  Twenty-sixth  day,  spastic  contractions  of  hands. 
Thirty-eighth  day,  temperature  rose  to  108.2°  F..  rectal.  Death 
on  fortieth  day,  rectal  temperature  one  hour  previous  being  no0  F., 
pulse  154.  Diagnosis,  infantile  paralysis  of  cerebral  type.  (Personal 
communication.  Dr.  G.  H.  Fellman,  Milwaukee.) 

Vital  centers  may  be  suddenly  and  overwhelmingly 
attacked.  In  fatal  cases  a  few  hours  only  may  elapse 
between  onset  and  death. 


PATHOLOGY.  95. 

H.  P.  K.,  j]/2  months.  In  same  house  with  cousin,  T.  P. ;  para- 
lyzed in  May.  June  ist,  onset.  Fever,  convulsions,  stupor,  eleven 
hours  from  onset  to  death.  (Personal  communication.  Dr.  Henri 
B.  Cole,  Blk.  River  Falls,  Wisconsin. ) 

THE  BRAIN. 

Diminishing  in  intensity  from  the  bulb  forward  and 
Upward,  infiltration  can  be  traced  over  the  cortex  of  the 
brain  to  the  vertex.  Hyperemia,  infiltration,  foci  of  round 
cells,  and  edema  have  all  been  observed  in  the  cortex,  and 
to  a  lesser  degree  in  the  white  substance  of  cerebrum  and 
cerebellum.  The  prognosis  as  to  life  in  the  encephalic  form 
is  much  more  favorable,  and  these  cases  have  not  provided 
much  autopsy  material.  In  cases  presenting  a  clinical 
picture  of  an  encephalitis  the  process  would  be  marked  in 
the  pia-arachnoid  and  the  subjacent  cortex.  Spastic  mono- 
plegias,  convulsions,  epilepsy,  hydrocephalus,  and  mental 
deficiency,  with  acute  tremor,  acute  ataxia,  and  nystagmus 
if  the  cerebellum  is  involved,  will  be  found  associated. 

THE  CEREBELLUM. 

Involvement  and  infiltration  of  the  cerebellar  substance 
at  the  decussation  produce  a  tremor  due,  from  irritation, 
to  the  alternate  action  of  groups  of  muscles  and  their 
antagonists.  This  tremor  is  slow,  coarse,  and  regular,  in- 
voluntary, but  of  the  intention  type,  and  associated  with 
a  spastic  and  relaxed  musculature.  Its  exact  analogue  has 
been  long  recognized  as  paralysis  agitans. 

In  1899  the  late  Professor  Brower  presented  to  his  class  in 
nervous  diseases  an  advanced  case  of  paralysis  agitans  as  a  typical 
case,  a  woman  of  60,  who  gave  her  own  history.  She  had  been 
acutely  ill  at  16  years  of  age  with  "brain  fever."  Was  subsequently 
as  we  saw  her,  with  spastic  and  atrophic  muscles,  tremor,  and  the 
propulsive  gait,  which  she  described  in  saying  that  she  ascended  and 
descended  stairs  successfully  only  by  "running."  This  woman 


%  IXFAXT1LE    PARALYSIS. 

stated  that  a  brother,  acutely  ill  at  the  same  period,  was  left  a  hope- 
less paralytic.  Professor  Brower  made  no  attempt  to  co-ordinate 
these  two  cases,  beyond  calling  the  attention  of  the  class  to  the  fact 
that  both  cases  began  acutely. 

The  tremor  may  extend  to  the  head,  tongue,  muscles 
of  trunk  and  extremities.  The  child  may  appear  to  be 
shivering  with  cold.  In  a  case  of  a  girl  of  16  the  tremor 
was  confined  to  face  and  tongue ;  a  paralysis  of  the  sterno- 
cleidomastoid  of  one  side  allowed  the  trembling  head  to  be 
drawn  well  toward  the  opposite  shoulder. 

An  invasion  of  the  cerebellar  cortex  may  be  followed 
by  a  "wild  ataxia."  This  comes  on  acutely  with  associated 
spastic  conditions,  nystagmus  and  scanning  speech.  It 
may  be  veiled  by  stupor  during  the  acute  stage,  and  be- 
come manifest  only  when  convalescence  is  established  and 
the  patient  active. 

Lesions  of  the  optic  thalamus  produce  an  athetoid  con- 
dition with  slow  weaving  of  the  affected  extremities,  and 
a  more  or  less  constant  vermicular  motion  of  the  torso  in 
children  still  in  arms.  Other  clinical  symptoms  of  cerebral 
involvement  are  usually  present,  with  a  cerebral  hemiplegia 
or  paraplegia.  The  following  case  was  seen  at  the  Hos- 
pital for  Deformities  and  Joint  Diseases,  New  York 
City:- 

F.  B.,  Yonkers.  Well-developed  male,  19  months.  Walked 
and  talked  at  14  months.  Acute  onset  April,  1911.  Unconscious 
nine  days.  High  fever;  opisthotonus ;  strabismus.  Five  weeks 
later,  paralysis  of  extensors  of  both  legs ;  spastic  condition  of  right 
and  left  great  toes;  spastic  and  relaxed  condition  of  both  arms. 
which  are  constantly  employed  in  slow,  vermicular  motion,  the  hands 
weaving  circles  which  extend  to  limit  of  range  above  head  and 
posteriorly.  Constant,  slow,  wriggling  motion  of  torso.  These  move- 
ments cease  in  sleep.  Makes  no  effort  to  sit,  stand,  or  speak. 

Head  hydrocephalic,  circumference  iSl/4  inches.  Fontanels 
unclosed.  Mentality  distinctly  disturbed,  but  recognizes  parents. 
Marked  irritability. 


PATHOLOGY.  97 

CEREBRUM  AND  CENTRAL  GANGLIA. 

Infiltration  from  the  involved  pial  vessels  has  been 
traced  up  and  over  the  hemispheres,  including  the  central 
g'yri.  Harbitz  and  Scheel  found  inflammatory  changes  in 
certain  parts  of  the  substance  of  the  hemispheres,  as  well 
as  the  cerebral  cortex,  and  consider  that  it  is  present  in 
these  localities  in  all  serious  and  fatal  cases.  They  found 
anatomical  evidence  of  a  very  severe  degree  of  cerebral 
invasion  and  softening,  in  the  case  of  a  man  of  39  years 
which  came  to  autopsy.  The  case  occurred  in  the  same 
locality  and  simultaneously  with  cases  of  poliomyelitis,  and 
for  this  reason,  and  because  the  inflammatory  process  in 
nature  and  extent  corresponds  with  that  of  acute  poliomye- 
litis, it  can  be  classed  with  certainty  with  that  disease. 

Male,  39,  presented  symptoms  of  meningoencephalitis,  namely, 
fever,  headache,  stiff  neck,  vomiting,  convulsive  seizures,  clouded 
consciousness,  and  some  rigidity  of  limbs.  Finally  coma  and  death 
occurred  after  twelve  days'  illness.  There  were  no  paralyses  or 
pareses.  At  necropsy,  aside  from  diffuse  hyperemia  of  the  central 
nervous  system,  there  were  softened  encephalitic  foci  in  the  right 
temporal  lobe,  and  in  the  gyrus  fornicatus  of  both  sides.  In  ad- 
dition, the  inflammation  extended,  though  with  lessened  intensity, 
to  the  basal  ganglia,  along  the  aqueduct  of  Sylvius,  through  the  en- 
tire medulla  oblongata,  and  was  even  demonstrable  in  the  cord. 
The  inflammation  had  the  same  characteristics  as  that  of  poliomye- 
litis ;  also  in  this  particular,  that  there  were  cellular  infiltrations  in 
the  pia  mater.  (Harbitz  and  Scheel.) 

Encephalitis  of  the  cerebral  cortex  is  now  known  and 
described  as  polioencephalitis  superior.  Three  classes  of 
cases  have  been  recognized,  according  to  localization  of 
the  lesion,  as : — 

1.  Rolandic.     (Cerebral  hemiplegia.) 

2.  Frontal.        (With  mental  and  moral  deterioration.) 

3.  Occipital.     (Blindness,  with  normal  eye-grounds  and  active 

pupils.) 


98  INFANTILE    PARALYSIS. 

DIGESTIVE  SYSTEM. 

An  invasion  and  inflammation  of  the  tonsils  and  sali- 
vary glands  were  discovered  early  in  the  experimental  work 
with  monkeys,  and  pointed  the  way  to  the  findings  in  the 
lymphatic  system  as  a  whole.  Strauss,  of  Cornell,  found 
acute  enlargement  of  the  solitary  follicles  and  Fever's 
patches  of  the  small  intestine,  and  an  acute  inflammation 
of  the  mesenteric  glands.  The  involvement  of  these 
lymphatics  was  found  in  every  case  where  the  intestines 
were  examined,  and  in  i  case  there  was  ulceration  of  the 
follicles  and  patches.  Inflammation  was  found  present 
early  in  serious  cases.  The  acute  swelling  of  the  follicles 
and  glands  was  very  marked  in  a  case  that  died  three  hours 
after  onset  of  paralysis. 

THE  SPLEEN. 

The  spleen  is  enlarged  and  congested,  showing  a 
marked  hyperplasia  of  the  Malpighian  bodies,  and  pro- 
liferation of  the  endothelial  cells. 

THE  LUNGS. 

The  lungs  are  congested,  and  areas  of  bronchopneu- 
monia  are  frequent.  Strauss  considers  this  an  aspiration 
pneumonia.  Considering  the  frequency  of  involvement  of 
the  muscles  of  respiration,  with  deficient  oxidation,  and  the 
invasion  of  the  adjacent  blood-vessels  of  the  cord,  the  pos- 
sibility of  a  toxic  pneumonia  must  be  considered,  until  the 
knowledge  of  the  lesions  of  this  protean  disease  is  further 
advanced. 

THE  LIVER. 

Mild  parenchymatous  changes  have  been  noted  in  the 
liver.  Necrosis  and  disintegration  of  the  liver-cells  are 
reported  by  Peabody  and  Draper. 


PATHOLOGY.  99 

THE  KIDNEYS. 

The  kidneys  show  congestion,  edema,  and  a  beginning 
degeneration  in  mild  cases,  with  an  acute  exudative  ne- 
phritis in  severe  and  rapidly  fatal  cases.  Clinically,  cases 
supposed  to  present  a  retention  have,  on  catheterization, 
been  found  to  be  suffering  from  anuria.  Anuria  might 
result  from  the  profound  action  of  the  virus  overwhelm- 
ing the  secretory  cells  of  the  uriniferous  tubules,  or  from 
a  total  inhibition  of  the  centers  for  innervation  of  these 
cells. 

THE  BLOOD. 

Evidence  of  the  destructive  action  of  the  living  virus 
throughout  the  system  indicates  that  it  is  carried  by  the 
blood-stream  to  all  organs  of  the  body  simultaneously  with 
its  localization  in  the  great  central  ganglion. 

THE  VISCERAL  LESIONS  OF  HUMAN  POLIOMYELITIS. 

During  the  past  summer  the  organs  from  n  children,  ranging 
in  age  from  3^/2  months  to  9^/2  years,  became  available  for  study. 
Of  the  ii  children,  10  died  on  the  third  to  the  eleventh  day  of  illness, 
and  i  child,  having  survived  the  acute  stage  of  poliomyelitis,  suc- 
cumbed two  months  later  to  laryngeal  diphtheria. 

All  the  fatal  cases  examined  by  us  showed  some  and  usually 
a  high  degree  of  hypertrophy  of  the  lymphoid  tissues.  The  affec- 
tion of  these  tissues  was  widespread,  if  not  universal,  and  included 
the  tonsils,  small  intestine,  thymus,  and  the  superficial  and  deep 
lymphatic  glands.  The  glands  about  the  trachea  and  bronchi  and 
those  of  the  abdominal  cavity  w-ere  usually  much  enlarged  and 
definitely  softened  in  consistence.  The  mucosa  of  the  large  intestine 
escaped  affection,  although  the  mesocolic  glands  did  not.  \Yhile  the 
cervical,  axillary  and  inguinal  nodes  do  not  become  prominent, 
they  all  showed  definite  enlargement  to  the  naked  eye.  The  spleen 
was  somewhat  enlarged  and  the  appearance  was  universally  altered. 
The  Malpighian  bodies  were  prominent,  and  the  pulp  was  increased 
and  of  dark  or  grayish  hue.  Defects  in  the  intestinal  mucosa  were 
never  observed.  The  necropsies  were  performed  a  few  hours  after 


100  1XFAXTILE    PARALYSIS. 

death,  so  that  the  organs  were  secured  in  a  state  free  from  post- 
mortem changes. 

The  characteristic  appearances  observed  in  the  parenchymatous 
organs  relate  to  the  lungs  and  the  liver.  The  lungs,  in  several  in- 
stances, show  within  the  capillary  and  other  small  vessels  a  con- 
siderable number  of  myeloid  cells  of  the  megakaryocytic  type. 
Similar  cells  are  found  in  some  sections  of  the  spleen;  but  the 
lesions  in  the  liver  are  conspicuous  and,  apparently,  constant.  They 
consist  of  hyaline  focal  necrosis  of  liver-cells,  followed  by  regen- 
eration and  invasion  by  lymphoid  cells  and  polynuclear  leucocytes. 
The  number  of  areas  of  necrosis  is  remarkably  large;  the  extent 
of  the  necrosis  varies  from  a  few  cells  to  an  eighth  of  a  lobule. 
The  liver-cells  appear  hyaline,  stain  deeply  in  eosin,  are  coalesced, 
and  are  sometimes  in  process  of  disintegration.  The  location  of 
the  necroses  is  remarkable ;  they  are  not  infrequently  adjacent  to 
the  portal  spaces,  but  they  are  far  more  common  about  the  central 
and  sublobular  veins.  The  smaller  ones  are  readily  overlooked ; 
the  larger  ones  resemble  the  "lymphoid  nodules,"  so  called,  of  the 
liver  in  typhoid  fever.  What  is  remarkable  is  the  large  number 
present  in  the  sections — a  dozen  or  a  score  or  more  of  separate 
areas  may  occur  in  an  ordinary  section.  The  rapidity  with  which 
regeneration  is  attempted  is  a  striking  feature;  proliferated  nuclei 
of  liver-cells,  arranged  often  in  double  rows  so  as  to  simulate  bile- 
ducts,  occur  in  all  the  specimens.  When  it  is  recalled  that  the 
obvious  illness  in  some  instances  was  only  of  three  or  four  days' 
duration,  and  in  most  cases  was  less  than  seven  days,  both  the  wide 
extent  of  the  necrotic  injury  and  of  the  marked  effort  at  repair 
are  worthy  of  being  noted. 

A  study  in  children  of  the  general  visceral  lesions  of  epidemic 
poliomyelitis  leads  us  to  place  the  disease  among  the  affections  in 
which  the  organs  generally  suffer  injury.  The  main  injury  appears 
to  be  inflicted  on  the  nervous  organs,  next  on  the  lymphatic  organs, 
and  last  on  the  parenchymatous  organs.  Of  the  last,  the  focal 
necrotic  lesions  of  the  liver  are  especially  impressive.  Whether 
the  organic  lesions,  exclusive  of  those  of  the  nervous  system,  are 
to  be  attributed  to  parasitic  action  or  to  the  action  of  toxic  elements 
of  parasitic  origin,  is,  at  present,  a  matter  of  conjecture.  But  the 
polymorphonucleocytosis  of  epidemic  poliomyelitis  is  caused  not 
only  by  the  lesions  of  the  nervous  system,  but  also  by  lesions  of  the 


Fig.  28. — Actual  shortening  of  left  leg.    Note  epiphysial  line. 


i 


Fig.  29. — Drop-foot  and  shortening.    Compare  with 
X-ray  of  club-foot  (Fig.  31). 


Fig.  30. — Paralysis  of  right  leg,  with  shortening,  at  9,  from  in- 
fantile paralysis  at  4  years  of  age.  Note  slender,  rarefied  tibia,  and 
atrophied  muscles  of  paralytic  leg. 


Fig.  31. — X-ray  of  foot,  showing  bony  deformity. 


PATHOLOGY.  101 

lymphatic  tissues  and  liver.  This  consideration  will  serve  to  explain 
certain  discrepancies  in  the  cell  findings  in  the  cerebrospinal  fluid 
removed  by  lumbar  puncture,  and  in  the  circulating  blood.  (Flex- 
ner,  Peabody,  and  Draper,  Journal  of  the  American  Medical  Asso- 
ciation, Jan.  13,  1912.) 

PATHOLOGIC  ANATOMY  OF  THE  CHRONIC  STAGE. 

The  Spinal  Cord. — "In  the  residual  stage  are  found 
patches  of  scar  tissue,  i  to  2  centimeters  in  length,  with 
atrophy  of  the  anterior  horns  or  even  of  half  the  cord. 
The  nervous  material  will  be  found  almost  entirely  absent. 
The  anterior  roots  at  the  level  of  the  cicatricial  patch  are 
decreased  in  size."  (Vulpius.) 

The  Muscles. — "Muscles  of  the  affected  parts  of  the 
limb  show  marked  change.  They  decrease  rapidly  in  size, 
and  exhibit  degenerative  atrophy  of  variable  distribution 
and  severity.  The  normal  fibers  are  distinguished  by  their 
bright-red  color,  while  the  degenerate  ones  are  of  a  yellow- 
ish-white hue.  Separate  fibers,  of  which  the  bundle  is 
composed,  can  hardly  be  distinguished.  Areas  of  streaky 
degeneration  are  sometimes  seen  lying  side  by  side  with 
healthy  fibers  in  a  muscular  bundle.  These  are  the  so- 
called  'tabbycat'  muscles.  A  considerable  deposit  of  fat 
may  take  place  in  and  around  the  degenerate  muscle. 

"Certain  muscles,  though  subnormal  in  size,  show  a 
more  or  less  exaggerated  red  color;  these  are  fibers  which 
have  undergone  disuse  atrophy  or  overstretching.  A 
faulty  position  of  a  limb  results  in  the  shortening  and 
wasting  of  some  muscles,  while  others  are  overstretched. 
Compensatory  hypertrophy  of  muscle  may  take  place." 
(Vulpius.) 

The  Tendons. — "The  tendons  also  participate  in  the 
process  of  atrophy.  This  is  to  be  attributed  to  the  disuse 
rather  than  degenerative  change.  They  become  smaller 


109  1XI-AXTILE    PARALYSIS. 

and  somewhat  weaker,  and  where  they  are  intersected  by 
degenerated  muscle  they  are  particularly  likely  to  yield, 
e.g.,  in  the  quadriceps  tendon."  (Vulpius.) 

The  Skeleton.—  "The  changes  in  the  skeleton  are  very 
remarkable.  The  long  bones  of  a  paralytic  limb  are  more 
slender  than  usual;  the  outer,  compact  layer  is  rarified, 
and  the  medulla  is  reduced  in  amount.  The  difference  in 


Fig.  32. — Club-foot  from  infantile  paralysis. 

length  is  particularly  marked,  and  may  amount  to  several 
centimeters;  a  difference  of  as  much  as  20  centimeters  has 
been  recorded.  The  bones  may  acquire  a  permanent  de- 
formity as  the  result  of  long-continued  faulty  position  of 
the  joints  and  the  unequal  stress  that  is  laid  upon  them 
in  consequence."  (Vulpius.) 

The  Joints. — "As  a  rule,  the  joints  are  relaxed;  the 
capsule  and  ligaments  are  overstretched,  the  articulation 
becomes  lost,  and  subluxation  follows,  or  even  complete 


PATHOLOGY.  1Q3 

dislocation,  with  the  familiar  changes  in  the  articular  sur- 
faces. In  other  cases  one  finds  more  or  less  marked  con- 
tracture  due  to  partial  paralysis  of  the  muscles;  with 
this  is  associated  unilateral  shortening  of  the  capsule." 
( Yulpius.) 


CHAPTER    V 

General  Symptomatology. 

THE  symptoms  of  poliomyelitis  are  as  varied  as  the 
extent  of  its  pathologic  lesions.  They  may  be  grouped 
under  three  general  heads : — 

1.  The  manifestations  of  an  acute  systemic  infection. 

2.  The  symptoms  of  an  acute  and  diffused  inflamma- 
tion of  the  central  nervous  system. 

3.  Signs  of  acute  and  chronic  localized  lesions  of  cord 
and  brain. 

Incubation. — The  period  of  incubation  has  not  been 
definitely  ascertained.  It  apparently  varies  with  the  viru- 
lence of  the  infection  and  the  susceptibility  and  resistance 
of  the  patient.  In  experimental  inoculation  of  apes,  in- 
vasion commonly  occurred  in  the  second  week,  although 
the  onset  appeared  as  early  as  three  days  and  as  late  as 
six  months  (Williams).  Two  to  ten  days  are  now  ac- 
cepted as  the  probable  period  in  human  subjects.  A  sus- 
ceptible child  whose  resistance  had  been  broken  by  unusual 
fatigue,  exposed  to  repeated  infections  from  hypervirulent 
sources,  might  present  a  very  limited  period  of  incubation. 
and  die  during  systemic  invasion.  Such  a  case  came  under 
the  writer's  observation  during  a  street  fair  in  a  western 
city.  A  child,  coming  from  a  healthy  and  uninvaded  terri- 
tory in  the  woods  to  the  town  where  the  epidemic  was  rife. 
was  taken  fairing  all  the  first  day  and  refused  to  go 
out  the  following  morning.  Onset  and  death  followed  in 
seventy-two  hours. 

Leegard,  of  Norway,  who  studied  and  reported  the 
Bratsburg  epidemic  of  54  cases  in  1899,  considered  the 
(104) 


GENERAL   SYMPTOMATOLOGY.  105 

period  of  incubation  in  some  cases  to  have  been  less  than 
twenty-four  hours. 

In  some  cases  the  incubation  period  has  apparently 
lengthened  to  three  weeks. 

.  I ura  of  Attack. — In  many  cases  there  have  been  noted 
a  series  of  initial  symptoms  before  the  actual  onset  of  the 
disease.  These  prodromata,  slight  in  themselves,  are  yet 
fairly  constant,  and  so  distinctive  as  to  form  valuable  points 
in  the  diagnosis  of  the  disease  in  this  early  stage.  A 
change  of  disposition  will  be  first  noted,  with  irritability 
and  peevishness.  An  unexplained  malaise  will  occur,  as 
in  the  case  of  the  child  who  refused  to  go  fairing.  The 
child  or  adult  may  endeavor  to  ignore  a  weakness  or 
prostration  so  unaccustomed.  A  feeling  of  sickness  or 
shakiness  will  be  experienced,  attended  with  a  slight  dizzi- 
ness or  even  vertigo.  This  vertigo  and  inco-ordination 
induce  an  ataxia  which,  taken  with  the  accidents  it  is  re- 
sponsible for,  form  the  aura  of  the  attack. 

The  aura  of  the  attack  in  a  child  is  manifested  by  trem- 
bling, and  a  stumbling  gait  or  unaccustomed  falls.  In  the 
adult,  owing  to  the  better  educated  conduction  paths  be- 
tween cord  and  brain,  the  stumbling  is  less  frequent,  but 
does  often  occur.  The  adult,  however,  will  experience  a 
slight  mental  confusion,  a  certain  cervical  tension,  and 
unaccounted  tremor  and  an  undoubted  ataxia.  The  large 
number  of  cases  in  both  children  and  adults  in  which  trauma 
is  given  as  a  cause  of  the  paralysis  are  many  of  them  cases 
in  which  the  aura  of  the  attack  has  been  unmistakably 
manifest. 

A  history  of  trauma  was  given  in  47  cases  of  635  in- 
vestigated by  Dr.  Lovett.  Of  these,  32  cases  gave  a  history 
of  accident  followed  almost  immediately  by  paralysis,  and 
the  balance  after  an  interval  of  some  days.  The  tables 
given  are  of  such  interest  in  this  connection  that  they  are 


106  INFANTILE    PARALYSIS. 

included.  It  will  be  seen  that  only  two  of  the  falls  can  be 
excluded  as  not  due  to  ataxia  and  inco-ordination, — child 
dropped  by  nurse ;  child  hit  by  stone. 

TRAUMA   PRECEDING   POLIOMYELITIS. 

Tabulation  of  47  cases,  excerpt  from  Lovett. 

Slight  accidents: — 

Slight  fall 20 

Fall  from  cradle 3 

Fall  from  swing  i 

Fall  from  carriage   3 

Fall  from  chair I 

Fall  from  automobile    I 

Walking,  skating  or  playing  (fall) * 5 

Dropped  by  nurse I 

Falling  under  other  children I 

More  serious  accidents: — 

Falling  from  third-story  window I 

Falling  from  first-story  window   I 

Stone  fell  on  head   I 

Gate  fell  on  foot I 

Fracture  of  tibia I 

Later  cases: — 

Fall  from  carriage,  chair  and  bed 3 

Fall,  paralysis  three  weeks  later I 

Injury :    Sprain  of  ankle 2 

Dr.  Gregor's  Instances. — A  child  was  at  the  wash- 
basin and  fell  while  crossing  the  room  for  towels;' a  boy 
of  6  was  observed  falling  about  the  house,  went  out,  when 
he  again  fell  and  was  carried  home;  a  woman  got  out  of 
bed  and  fell  down,  becoming  dazed. 

A  fall  down  steps,  down  stairs,  down  a  bank,  or  the 
grassy  terrace  surrounding  a  house,  have  all  been  men- 
tioned to  the  writer  as  causes  of  the  paralysis.  The  fol- 
lowing case  is  typical  of  such  histories,  but  the  osteopathic 
deduction  from  the  fall  is  as  original  as  characteristic: — 


GENERAL    SYMPTOMATOLOGY.  107 

Mary  M.,  5  years  of  age;  slight  fall  two  days  before  onset. 
Vomiting;  pain  in  back  and  limbs;  temperature  104°  F.,  fourth  day 
100°,  where  it  remained  for  two  weeks  or  more.  Paralysis  fourth 
day;  both  lower  extremities  involved,  left  more  than  right ;  deltoids 
and  shoulder  group  most  affected;  stiffness  of  neck  and  spine. 
Patient  acquired  almost  perfect  control  of  the  arms  and  could  use 
legs  fairly  well  when  last  seen.  Parents  became  dissatisfied  with 
slow  (?)  progress  of  case  and  called  an  osteopath,  who  diagnosed 
condition  as  "fracture  of  the  neck"  due  to  fall  two  days  before 
onset.  (Dr.  Pretts,  Plattsville,  \Vis.,  August  i,  1908.) 

Here  the  ataxia  preceding  more  serious  trouble  is  well 
illustrated : — 

B.  N.,  4  years  of  age,  male ;  predisposing  cause  autointoxica- 
tion. Complained  of  pain  in  posterior  surfaces  of  thigh.  Walked 
like  an  old  man,  and  also  held  to  the  wall  for  support,  for  two  days. 
Stupor.  Painful  point  over  posterior  branch  of  lower  lumbar 
nerves.  Paralysis :  Both  legs  and  muscles  of  erector  spinse  group. 
July  30,  1908:  Can  sit  up  erect,  extend  right  foot,  flex  and  extend 
leg.  and  flex  thigh.  Left  leg:  Extends  and  flexes  thigh,  but  can- 
not flex  or  extend  foot.  (Dr.  G.  H.  Fellman,  Milwaukee,  April  29, 
1908.) 

A  clear  history  of  aura  of  onset  in  a  case  of  adult 
poliomyelitis  is  given: — 

G.  G.  H.,  aged  40 ;  onset  August  9,  1907.  A  certain  degree  of 
dizziness  extending  over  two  weeks  preceded  the  onset  of  the  dis- 
ease. On  August  9th,  while  at  work,  he  began  to.  suffer  from  a 
headache,  which  rapidly  grew  in  intensity  and  became  so  severe 
that  the  patient  spoke  of  it  as  the  most  agonizing  pain  he  had  ever 
experienced  and  should  never  forget.  Prostration,  high  fever, 
vomiting,  appeared  and  continued  for  four  days;  on  the  fifth  day 
of  onset  the  patient  had  totally  lost  the  use  of  his  left  arm ;  during 
the  sixth,  seventh  and  eighth  day  the  two  lower  extremities,  the 
trunk  muscles  and  the  muscles  which  support  the  head  were  in- 
volved in  the  paralysis,  with  temporary  paralysis  of  the  bladder, 
and  paresis  of  the  right  shoulder  muscles.  [Abstracted  from 
Archambault's  "Poliomyelitis  in  the  Adult"  (Albany).  X.  Y.  Medi- 
cal Journal,  August  8,  1908.] 


108  INFANTILE    PARALYSIS. 

This  man  of  40  gives  a  distinct  history  of  dizziness 
lasting  for  two  weeks  preceding  the  terrific  onset  of  the 
disease,  which  also  continued  for  ninety-six  hours  before 
the  character  of  the  attack  was  clearly  defined  by  the  on- 
o  Miiing  paralysis.  Adults  are  better  able  to  give  a  lucid 
account  of  the  character  of  their  symptoms  than  children ; 
and  if  the  subject  of  poliomyelitis  in  the  adult  had  not 
been  almost  wholly  overlooked  or  ignored,  we  could  doubt- 
less present  a  series  of  symptoms  so  uniformly  present  as 
to  make  diagnosis  of  the  preparalytic  stage  of  poliomye- 
litis in  the  adult  a  definite  entity. 

Onset. — The  symptoms  of  onset  are  also  the  symptoms 
of  the  arrested  or  so-called  aborted  form  of  the  disease. 
The  onset  is  cumulative  rather  than  abrupt;  the  history 
of  an  absolutely  abrupt  onset  of  this  disease  is  due  to  the 
fact  that  slight  febrile  conditions  are  often  overlooked 
in  children  and  ignored  in  adults.  The  seeming  sudden- 
ness of  onset  is  due  to  the  simultaneous  rise  in  temperature. 
pulse  and  respirations,  together  with  meningism,  basilar 
headache,  tremor,  convulsive  movements,  and  vomiting, 
with  obstipation,  and  retained  or  suppressed  urine.  The 
onset  occurs  very  often  in  sleep,  the  patient  waking  with 
high  fever,  and  all  the  other  symptoms  enumerated.  It 
may  begin  with  a  chill;  it  occasionally  begins  insidiously. 
with  the  graduated  approach  characteristic  of  typhoid 
fever. 

A  marked  increase  in  the  pulse  rate  to  140-150  is  per- 
haps the  most  constant  feature  of  onset.  This  is  accom- 
panied by  a  sharp  rise  in  temperature  to  104-106°  F. 
Respirations  are  rapid,  increasing  to  40  or  60  per  minute 
with  no  apparent  cause.  An  immediate  paresis  of  dige- 
tion  is  evidenced  by  severe  and  repeated  vomiting,  and 
constipation.  Tnco-ordination,  tremor  and  ataxia  are  in- 
creased, and  prostration  is  marked.  Occipital  headache 


GENERAL    SYMPTOMATOLOGY.  109 

and  pain  of  an  agonizing  character  between  the  shoulders 
and  in  the  lumbar  region  are  usually  present.  Cervical 
tension  or  rigidity  will  be  complained  of,  or  the  whole 
spine  may  be  spastic.  Sleep  is  broken  by  muscular  twitch- 
ings,  which  vary  from  a  light  jerking  of  the  extremities 
to  convulsive  movements  violent  enough  to  throw  the  pa- 
tient from  the  bed.  Urine  is  scanty,  retention  frequent, 
and  suppression  not  infrequent. 

The  type  of  onset  varies  somewhat  in  epidemics ; 
meningism  is  the  most  marked  feature  at  times,  while 
gastroenteritis  was  more  prominent  in  the  Germanic  epi- 
demics of  1908-9.  Some  cases  begin  with  an  angina 
simulating  tonsillitis,  and  in  every  epidemic  a  small  per- 
centage of  cases  develop  with  an  acute  multiple  neuritis. 

Circulatory  System. — Epistaxis  occurred  during  the 
onset  in  a  number  of  the  Wisconsin  cases.  Nasal  hemor- 
rhage may  have  been  due  to  an  individual  susceptibility; 
it  is  more  probable,  however,  that  an  extreme  congestion 
of  the  nasal  mucosa  is  excited,  which  is  conducive  to 
hemorrhage.  We  know  that  the  nasal  and  pharyngeal 
mucosa  and  tonsillar  tissues  provide  an  atrium  for  the 
infectious  virus.  We  also  know  that  the  walls  of  blood- 
vessels of  the  cord  are  rendered  pervious  by  the  action  of 
this  virus,  and  we  suspect  that  the  virus  in  some  instances 
travels  by  way  of  the  nasal  mucosa  and  cribriform  spaces 
<>f  the  ethmoid  "directly  to  the  cerebral  mucosa.  It  would 

• 

appear  that  a  congestion  of  the  nasal  mucosa,  destruction 
of  the  integrity  of  the  wall  of  the  nasal  vessels,  and  a  con- 
current epistaxis  may  accompany  the  onset.  Epistaxis  at 
the  onset  occurred  frequently  during  the  Cornwall 
<  Kngland')  epidemic  of  IQII. 

The  heart  is  much  accelerated,  often  to  double  the 
usual  rate.  In  the  cases  among  children  which  fell  under 
the  writer's  personal  observation,  the  pulse  during  the 


no 


1XFAXTILE    PARALYSIS. 


acute  stage  ranged  from  160  up,  being  counted  with  diffi- 
culty beyond  that  point.  Dakin,  in  his  report  of  the 
Mason  City  cases,  states  that  the  pulse  is  usually  high,  100 
to  150  in  adults  and  ranging  up  to  200  in  children.  In  a 
majority  of  cases  the  child  is  not  seen  until  this  stage  is 
passed  and  paralysis  has  supervened,  when  the  pulse  im- 


Fig.  33. — Aunt,  18  years  of  age,  poliomyelitis  at  9  years  of  age, 
and  niece,  a  normal  child,  3  years  of  age :  paralysis,  atrophy,  con- 
tractures  and  trophic  non-development.  (From  series  of  Dr.  Louis 
Ager,  of  Brooklyn.) 

mediately  declines  to  about  100.  The  fall  to  normal  may 
be  delayed  until  invasion  is  over  and  a  recession  of  the 
paralysis  is  evident.  The  pulse  is  weak  and  compressible 
in  character,  and  may  show  marked  irregularity.  This 
early  and  violent  change  in  the  heart  action  is  probably 
due  to  irritation  of  the  accelerator  branches  of  the  vagus. 
It  may  be  caused  by  the  virus  in  the  blood  acting  on  the 


GENERAL    SYMPTOMATOLOGY.  HI 

center  for  these  accelerator  fibers,  as  it  occurs  before  there 
is  any  evidence  of  destructive  lesions  in  that  area.  This 
acceleration,  however,  may  be  due  to  the  direct  irritant  of 
the  virus  on  the  heart  muscle;  such  was  considered  by 
Rekseh,  of  Rhenish  \Yestphalia,  who  reported  the  fol- 
lowing case  :— 

A  girl  aged  8,  after  a  mild  prodromal  stage,  developed  a  flaccid 
palsy  of  both  legs.    Her  general  condition  was  excellent,  and  all  of 


Fig.  34. — Posterior  view  of  Fig.  33. 

the  organs,  especially  the  heart,  appeared  healthy,  when,  without 
any  warning,  death  occurred  suddenly  on  the  second  day,  being 
probably  due  to  the  action  of  toxins  on  the  heart  muscle. 

The  increase  in  the  pulse  rate  may  be  independent  of 
temperature.  The  pulse  rate  is  often  unmentioned  in  other- 
wise complete  reports,  or  it  is  manifest  that  the  pulse 
recorded  was  taken  in  the  later  paralytic  stage.  The  com- 
plete report  given  by  Frizzell  of  the  Princeton  student's 
case  is  indicative  of  the  typical  cardiac  change.  It  is  stated 
that  this  patient  was  seen  fifty-six  hours  after  the  first 


112  IXFAXTILE    PARALYSIS. 

intimation  of  illness,  with  a  pulse  of  90.  The  evening  of 
that  day  it  reached  120.  The  day  was  October  3ist;  Nov. 
i>t,  the  pulse  declined  to  90;  Nov.  2d,  to  80  beats,  and 
\i»v.  3d,  when  paralysis  appeared,  the  pulse  declined  to 
60-64,  near  tne  normal  rate  for  a  young-  adult  male  with  a 
sound  cardia. 

A  decrease  in  the  pulse  rate  occurs  in  the  postfebrile 
drop,  and  in  cases  of  the  sudden  fulminating  type.  Per- 
-istent  headaches,  and  a  subnormal  pulse  and  temperature 
followed  an  attack  of  the  arrested  type  in  an  adult  for  a 
period  of  eight  weeks.  A  pulse  rate  of  42  was  reported 
by  Dr.  Gregor  and  Dr.  Hopper,  during  the  Cornwall 
( England )  epidemic  :— 

A.  ].,  male,  aged  25.  A  perfectly  healthy  man  up  to  the  time 
of  his  fatal  illness ;  no  history  of  tubercle ;  Sept.  22d,  severe  frontal 
headache;  retching;  rose  at  n  A.M..  went  for  a  short  voyage  on  the 
bay ;  on  the  way  home  became  sick,  and  vomited  ( not  seasickness  > 
Arrived  at  dock  at  5  P.M.  Too  ill  to  walk  home,  but  walked  up 
steps  to  a  cab.  5.30  P.M.,  pulse  42;  curled  up  in  very  lethargic  state ; 
feet  cold ;  did  not  speak,  but  put  out  tongue  when  told ;  vomited  a 
brown,  grumous  fluid;  became  comatose;  died  at  8  o'clock  P.M. 
Post  mortem:  All  organs  healthy  except  brain;  meninges  much 
•congested.  Lateral  ventricles  distended  with  fluid.  Encephaloid 
type. 

Vasomotor  control  is  disorganized.  Sweating  is  fre- 
quent and  in  some  epidemics  of  such  a  profuse  character 
and  so  constant  that  it  is  spoken  of  as  a  cardinal  symptom 
of  the  disease.  The  conjunctiva  may  be  congested.  The 
face  assumes  a  mask  of  brilliant  red  and  white.  Later, 
the  paralyzed  extremities  become  ecchymosed,  bluish  in 
appearance,  and  cold  to  the  touch. 

Temperature. — A  chilly  sensation  sometimes  accom- 
panies the  onset  in  the  adult  and  more  rarely  a  distinct 
chill  occurs.  It  is  probable  that  this  occurs  not  infrequently 
among  young  children,  being  overlooked  or  taking  the 


GENERAL    SYMPTOMATOLOGY.  113 

form  of  a  slight  convulsion,  which  is  the  way  a  rigor  is 
usually  manifest  in  infancy. 

At  the  onset  of  the  attack  the  temperature  jumps  to  or 
near  the  maximum  point  attained.  The  temperature  is 
high,  rising"  to  104-106°  F.  for  a  short  period  of  time,  when 
it  declines  by  crisis  to  about  100°,  except  in  the  most 
serious  cases.  It  may  rise  higher,  but  105°  is  the  average 
elevation.  The  temperature  is  variable  and  may  be  mis- 
leading if  this  initial  rise  has  not  been  noted.  The  tem- 
perature is  not  a  reliable  indicator  of  the  severity  of  the 
attack,  but  a  high  temperature  with  correspondingly  severe 
onset  usually  indicates  extensive  impending  paralysis. 
The  temperature  declines  by  crisis  before  the  paralysis  is 
manifest  in  the  majority  of  cases.  It  remains  at  or  near 
loo  while  the  paralysis  is  extending,  and  then  drops  to 
subnormal  in  uncomplicated  cases.  The  surface  tempera- 
ture of  the  affected  parts  is  depressed. 

The  burning  fever  of  onset  is  sometimes  found  un- 
endurable by  the  victim.  R.  V.,  a  lo-year-old  boy  reported 
by  Marquardt,  of  La  Crosse,  sought  a  garden  sprinkler 
and  laid  under  it,  developing  a  paralysis  of  all  four  extremi- 
ties. His  temperature  when  seen  was  102°.  Its  height  at 
onset  can  only  be  estimated.  There  is  undoubtedly  grave 
irritation  of  the  heat  centers  in  a  majority  of  cases. 

The  temperature  and  symptoms  are  not  infrequently 
mistaken  for  heat  stroke:— 

A  child  dying  in  a  paralytic  or  comatose  condition  might  have 
been  regarded  as  a  case  of  sunstroke.  One  such  example  occurred 
in  Devonshire,  where  two  children  were  supposed  to  have  died  of 
sunstroke,  whilst  a  child  who  had  been  staying  in  the  same  house 
developed  poliomyelitis  immediately  on  its  return  to  Plymouth.  It 
is  more  than  likely  that  both  the  fatal  cases  were  infected  with 
poliomyelitis,  more  especially  as  they  were  young  children  who  had 
not  been  exposed  to  the  sun.  (Soltau,  Brit.  Mecl.  Jour.,  Nov.  4, 
1911.  ) 

8 


114  1XFAXTILE    PARALYSIS. 

The  temperature  of  the  cases  of  the  arrested  or  so- 
called  abortive  forms  is  not  always  secured.  The  mother 
will  say  that  the  child  had  a  high  fever  for  one  night  only. 
Such  a  case  is  given  where  the  temperature  was  secured  :— 

H.  A.,  male  aged  7.  residing  on  a  farm  five  miles  away. 
Onset  sudden,  July  I,  1910.  July  2d,  temperature  102.5°  F. ;  severe 
occipital  headache ;  pain  and  tenderness  of  spine.  July  3d.  tempera- 
ture normal ;  pain  and  tenderness  had  disappeared.  Two  other  chil- 
dren in  same  house  were  ill.  June  29th  and  July  ist.  with  similar 
symptoms.  One  recovered  in  a  few  days;  the  other  developed 
typical  poliomyelitic  paralysis  of  the  arm.  (Dr.  Fred.  Albert. 
Mason  City,  la.) 

The  arrested  type  may  show  as  high  a  temperature  as 
serious  or  fatal  cases.  The  fever  in  complicated  cases 
may  be  continuous  or  rise  to  the  same  point  as  that  of 
sunstroke.  Dr.  Fellman,  of  Milwaukee,  reported  a  case 
of  the  cerebral  type,  which  developed  a  temperature  of 
108.5°  t°  no0,  per  rectum,  in  the  fourth  week.  The  case 
was  fatal. 

Respiratory  System. — Sneezing  is  a  frequent  early 
symptom.  Coryza  is  so  rare  an  accompaniment  of  this- 
disease  that  its  presence  at  the  onset  is  probably  coinci- 
dental only.  A  pharyngeal  angina  occurs  with  more  .fre- 
quency; the  tonsillar  tissue  has  been  found  infected  with 
the  virus,  which  would  account  for  pharyngeal  and  tonsillar 
congestion. 

Respiration  is  profoundly  affected  in  cases  with  a  severe 
onset  or  extensive  lesions.  Respirations  are  at  first  rapid, 
rising  to  40  or  60  per  minute  with  no  apparent  cause. 
This  rise  may  be  attributed  to  the  irritation  of  the  phrenic 
nerve  at  its  common  origin  with  the  spinal  branche- 
the  spinal  accessory.  A  marked  increase  of  the  number 
of  respirations  per  minute,  due  to  irritation  of  the  phrenic 
supply  of  the  diaphragm,  occurs  with  cervical  tension  and 


GENERAL   SYMPTOMATOLOGY.  115 

hyperextension  of  head  due  to  spasticity  of  muscles  sup- 
plied by  cervical  plexus.  (Spinal  accessory  and  second, 
third  and  fourth  cervical.)  The  lungs  are  found  clear. 
Rapid  respiration  does  not  occur  in  cases  of  a  very  mild 
type,  nor  is  it  seen  in  cases  of  the  arrested  type  with  a 
mild  onset.  It  reaches  normal  with  the  lowering  of  the 
fever  and  the  appearance  of  paralysis.  Two  cases  are 
given,  one  of  the  arrested  type,  one  .of  the  paralytic,  both 
with  very  rapid  respirations  at  onset:— 

No.  10.  J.  L.,  6  years ;  direct  exposure ;  sudden  onset ;  chill ; 
vomiting;  pulse  150;  temperature  102.4°;  respiration  60;  no  paral- 
ysis ;  recovered. 

Xo.  24.  K.,  i  year;  indirect  exposure;  sudden  onset;  vomiting; 
pulse  180;  temperature  104°;  respiration  80;  muscular, twitching; 
prostration ;  sweating ;  spasticity ;  paralysis  of  anterior  tibial ;  con- 
tractures  ;  improving.  (Dakin's  series.) 

Should  the  case  prove  to  be  one  of  the  acute  ascending 
type  of  paralysis,  the  respirations  will  remain  elevated,  or 
after  a  brief  drop  will  again  accelerate,  becoming  feeble 
in  quality  and  somewhat  irregular.  This  second  or  delayed 
involvement  is  due  to  a  beginning  paralysis  of  the  muscles 
of  respiration,  the  chest  walls  remaining  fixed  and  the 
breathing  Assuming  the  abdominal  type.  The  diaphragm 
may  be  paralyzed. 

\Yith  diaphragmatic  paralysis  the  upper  abdomen 
recedes  during  inspiration  and  is  protruded  during  ex- 
piration. Such  a  case  may  present  a  mild  paresis  only,  a 
normal  temperature,  and  be  fully  conscious,  when  sudden 
paralysis  of  respiration  and  death  occur. 

Dyspnea  is  marked,  and  the  acceleration  of  the  heart 
shows  involvement  of  the  vagus.  The  Cheyne-Stokes 
syndrome  may  occur  in  both  types  of  paralytic  involvement 
of  respiration. 

The  muscles  of  one  side  of  the  chest  may  be  paralyzed, 


116  1X1. \\T1LE    PARALYSIS. 

and  the  chest  immobile,  while  the  respirations  are  regular 
but  feeble,  and  the  respiratory  excursion  of  the  other  half 
of  the  chest  still  evident.  This  type  of  breathing  is  para- 
lytic. It  is  a  bad  symptom,  but  cases  have  been  known  to 
recover. 

A  very  rapid  paralysis  of  respiration  is  due  to  bulbar 
involvement.  Such  a  case  may  present  a  mild  paresis 
only,  a  normal  temperature,  and  be  fully  conscious,  when 
sudden  paralysis  of  respiration  and  death  occurs.  Cheyne- 
Stokes  syndrome  indicates  involvement  of  the  vagus. 

Digestive  Tract. — As  has  been  well  said,  there  is  an 
immediate  paresis  of  digestion  with  the  onset  of  poliomye- 
litis. It  is  evidenced  by  anorexia,  vomiting,  foul  breath, 
sordes,  and  a  disordered  elimination  which  may  take  the 
form  of  diarrhea,  but  in  the  vast  majority  of  cases  it  is 
manifested  by  a  stubborn  constipation  with  colic,  tympany 
and  meteorism. 

Lack  of  appetite  accompanies  the  prodromal  stage; 
nausea  and  retching  may  or  may  not  precede  the  vomiting. 
Vomiting  is  sudden  and  repeated.  It  may  be  constant 
for  two  or  more  days,  and  is  sometimes  of  the  violent  and 
projectile  type.  The  vomiting  is  often  attributed  to  faulty 
digestion  or  an  indiscreet  dietary  (green  apples,  sausage. 
saner  kraut).  The  outraged  stomach  disgorges  food  it  is 
unable  to  assimilate,  but  repeated  vomiting  after  evacua- 
tion is  due  to  irritation,  probably  at  the  center.  Projectile 
vomiting  may  be  so  violent  that  the  vomitus  stains  the  wall 
or  ceiling  of  the  patient's  room.  Wickmann  reports  a  case 
of  a  woman  vomiting  with  such  force  as  to  dislocate  her 
jaw. 

The  vomiting  of  a  brown,  grumous  material  is  reported 
as  occurring  late  in  many  fatal  cases.  The  coffee-ground 
appearance  of  partly  digested  blood  is  suggested  by  these 
reports,  and  may  result  from  an  epistaxis  with  swallowing 


GENERAL    SYMPTOMATOLOGY.  117 

of  the  blood  by  the  unconscious  patient;  exact  knowledge 
on  this  point  is  to  be  acquired.  Vomiting  of  the  ordinary 
type  was  present  in  62  of  the  150  tabulated  \Yisconsin 
cases,  of  \vhich  i  case  is  given:— 

L.  S.,  male,  aged  5  years;  pain;  vomiting;  marked  constipa- 
tion ;  prostration ;  nervous  and  irritable ;  temperature  104°  ;  rash ; 
convulsive ;  both  heels  drawn  back  upon  buttocks ;  sensory  nerves 
very  acute  in  beginning  of  case,  slight  handling  producing  severe 
pain ;  paralysis  of  both  legs.  Oct.  6th,  unable  to  sit  alone ;  legs 
lie  extended,  recovering  motion  in  thigh  muscles.  (Dr.  G.  \Y. 
Menika,  Readstown.  Wis.,  Sept.  20,  1908.) 

It  is  to  be  noted  in  this  case  that  vomiting  and  constipa- 
tion were  present  at  the  onset,  but  in  the  report  the 
emphasis  is  put  on  the  constipation.  The  checking  of  the 
elimination  in  these  cases,  which  is  most  frankly  manifested 
by  a  stubborn  paresis  of  the  bowels,  should  not  be  ignored. 
It  is  a  constant  symptom;  it  is  a  dangerous  condition;  in 
its  detection  and  relief  lies  our  only  present  hope  of  lessen- 
ing or  preventing  the  oncoming  paralysis.  It  is  interesting 
and  suggestive  to  note  that  in  experimental  inoculation  of 
monkeys  the  virus  introduced  into  the  digestive  tract 
proved  inactive  unless  peristalsis  was  artificially  inhibited. 

Constipation  is  present  in  a  vast  majority  of  cases. 
Diarrhea  is  the  pre-existing  condition  to  this  fecal  stagna- 
tion in  some  cases,  and  denotes  an  effort  of  the  digestive 
tube  to  cast  off  the  virus.  In  this  country  diarrhea  is  most 
often  noted  in  the  arrested  or  abortive  type  of  case;  the 
concurrent  diarrhea  noted  in  other  members  of  the  family 
during  the  progress  of  a  case  is  a  very  certain  indication 
that  they  have  taken  the  infection.  Diarrhea  was  reported 
as  a  more  constant  symptom  in  the  Westphalia  epidemic 
of  1908  (Krause).  The  bowel  movements  are  large.  The 
fecal  stagnation  is  due  to  a  temporary  paresis  of  the  tract ; 
it  is  very  resistant  to  catharsis  and  colonic  flushings.  In 


118  INFANTILE    PARALYSIS. 

the  carefully  watched  case  of  the  Princeton  student  the 
bowels  "were  moved  only  with  great  difficulty  for  a  month" 
from  the  time  of  onset,  and  this  case  was  so  mild  that  it 
just  escapes  classification  as  one  of  the  arrested  type. 

The  bowel  movements  are  foul  until  free  defecation  is 
established;  thereafter  the  stool  appears  to  be  normal. 

The  tongue  is  red  at  first,  the  papillae  of  the  anterior 
half  noticeably  dilated  and  scarlet ;  it  subsequently  becomes 
coated,  and  sordes  gathers  on  the  teeth  and  gums. 

Genitourinary  System. — The  urine  is  scanty  and  high 
colored.  Albumin,  is  not  constant,  but  is  found  in  a  certain 
percentage  of  cases.  An  acute  exudative  nephritis  has 
been  reported.  .Frequent  micturition  occurs  early,  the 
symptom  of  a  mild  cystitis  due  to  elimination  of  the  virus 
by  the  kidneys.  Retention  or  suppression  may  follow. 
Retention  of  the  urine  is  a  common  occurrence.  It  is 
stated  to  have  occurred  n  times  in  150  Wisconsin  cases, 
but  it  is  often  overlooked.  Retention  is  due  to  a  temporary 
paresis  of  the  walls  of  the  bladder,  together  with  scanty 
secretion.  \Yhen  the  paralysis  extends  to  the  urinary 
sphincter  there  is  incontinence ;  this  is  somewhat  rare,  and 
always  temporary  in  uncomplicated  cases.  Delayed  urina- 
tion and  dysuria  may  occur.  Anuria  and  suppression  have 
been  noted  in  rapidly  fatal  cases  of  the  spinal  type.  Reten- 
tion and  overflow  may  occur.  Scanty  secretion  and  re- 
tention are  features  of  the  first  of  the  following  cases; 
retention  and  incontinence  of  the  second:— 

Princeton  student,  21  years;  onset  Oct.  29,  1910;  Oct.  3ist. 
pulse  90  to  120;  temperature  101°;  respiration  22;  last  urination 
Nov.  2d,  6.30  P.M.;  Nov.  3d,  unable  to  urinate;  lumbar  paraly<i- 
same  day.  Catheterized,  scanty  flow  of  urine ;  pressure  over  sym- 
physis  used ;  bladder  paralysis  lasted  for  twelve  days ;  bowels  were 
moved  only  with  great  difficulty  for  a  month.  (Dr.  Frizzell,  N.  Y.  i 

CASE  XVI. — D.  G.,  age  2l/2  years;  acute  onset  August  8th; 
vomiting,  retraction  of  head,  retention  of  urine  and  distended 


GENERAL    SYMPTOMATOLOGY.  119 

bladder,  with  diagnosis  of  intussusception  of  bowel.  Removed  to 
hospital  and  operated;  nothing  found  but  an  excessively  distended 
bladder.  August  i8th,  paralysis  of  both  legs  and  right  arm  cleared 
diagnosis.  (Reported  by  Lovett  and  Jones,  Bulletin  Mass.  State 
Board  of  Health,  June,  1910. ) 

C.  T.,  male,  i  year  6  months;  onset  August  21,  1911;  drowsy, 
febrile ;  clonic  spasm ;  opisthotonus.  Paralysis :  August  23d,  all  four 
limbs  and  back ;  retention  of  urine  and  overflow ;  death  August  28th. 
(Dr.  Moss-Blundell,  Huntingdonshire.) 

With  an  irritant  and  destructive  process  in  the  lumbar 
and  sacral  cord,  and  frequent  involvement  of  the  bladder, 
it  is  doubtful  that  the  genital  organs  wholly  escape  func- 
tional and  organic  alteration.  There  seems  to  be  little  ob- 
servation recorded  on  this  point.  The  following  case  is  the 
only  one  included  in  the  \Yisconsin  report : — 

\Y.  B.,  male,  6  years;  onset  September  26,  1908;  chill,  tempera- 
ture 103° ;  rapid  pulse;  headache;  delirium;  apathy;  stupor;  rigidity 
of  neck ;  dyspnea ;  pain  and  tenderness  over  the  whole  body ;  photo- 
phobia ;  constipation ;  semierected  penis  all  the  time ;  Kernig's  sign 
present.  Paralysis :  upper  part  of  back  and  right  and  left  arm  and 
forearm,  but  not  hands.  (Dr.  L.  A.  Larsen,  Coif  ax,  Wis.) 

A  male  adult  presenting  an  incomplete  transverse  myelitis  with 
acute  onset  had  great  pain  in  the  testicles,  followed  by  slight  paral- 
ysis  of  the  quadratus  femoris.  \Yith  a  diagnosis  of  probable  polio- 
myelitis the  spinal  fluid  from  this  case  was  injected  into  a  monkey, 
which  became  paralyzed  six  months  subsequently.  (Williams:  Dis- 
cussion, Section  of  Medicine,  Penna.  Medical  Society.  Penna. 
Medical  Journal,  December,  1911.) 

Cutaneous  System. — Sweating  may  be  profuse  and  has 
been  reported  as  a  characteristic  symptom  in  some  out- 
breaks. It  is  not  constant. 

Cutaneous  hyperesthesia  is  common;  it  may  take  the 
form  of  a  subjective  sensation,  the  child  complaining  that 
there  are  flies  walking  across  the  skin,  etc.  One  little  girl 
said  the  mosquitoes  were  killing  her.  The  cutaneous 
temperature  sense  may  be  exalted  or  depressed;  a  hot- 


120  IXFAXTILE    PARALYSIS. 

water  bag  may  be  agreeable  to  the  paralyzed  leg  and  un- 
supportable  to  its  fellow.  Tactile  sensation  may  be  de- 
layed or  exalted. 

Yasomotor  changes  of  the  cutaneous  surface  occur  in 
the  paretic  member,  which  is  congested  in  appearance, 
with  a  lowered  temperature. 

A  skin  rash  is  found  in  something  more  than  10  per 
cent,  of  the  cases  and  is  often  overlooked.  The  rash  is 
multiform  in  character;  it  may  be  erythematous  or  urti- 
carial  in  appearance,  morbilliform,  petechial,  papular, 
pustular,  or  purpuric. 

The  measles-like  rash  is  most  common;  it  frequently 
leads  to  a  diagnosis  of  measles.  It  consists  of  patches. 
not  so  large  as  the  typical  measles  blotch,  but  otherwise 
resembling  it  closely.  It  does  not,  however,  appear  on  the 
face  and  at  the  hair  line,  as  in  the  classical  measles  rash, 
but  is  found  first  on  the  torso,  spreading  from  there  to  the 
extremities,  and  to  the  dorsum  of  the  feet. 

All  of  these  varieties  of  rash  were  seen  in  the  \Yisconsin 
epidemic.  A  well-developed  scarlatinal  erythema  occurred 
in  a  child  of  6  years  with  paraplegia  and  constipation.  A 
fine  pustular  rash  was  seen  in  2  fatal  cases  in  brothers. 
covering  the  torso  of  one  and  barely  noticeable  in  the 
other;  the  rash  was  fine  but  distinctly  pustular.  Purptira 
appeared  on  the  hips  and  thighs  of  a  rapidly  fatal  case. 

S.  W.,  4 years,  male;  onset  August  4,  1908,  with  pain,  vomiting, 
delirium  and  twitching,  but  no  convulsions ;  temperature  higli ; 
paralysis  of  both  lower  and  both  upper  extremities,  trunk  and  neck 
muscles;  rash  resembled  measles,  very  intense;  atrophy.  (Dr.  A. 
W.  Myers,  Milwaukee.) 

N.  O.,  male,  2  years;  onset  October  10,  1908,  with  vomiting 
and  diarrhea ;  fever ;  small,  pimply  rash  about  trunk  and  neck ; 
paralysis  of  both  lower,  atrophy  of  left,  recovery  of  right  ex- 
tremities. (Dr.  C.  E.  Armstrong,  Oconto,  Wis.) 

Dr.  Anderson,  of  Nebraska,  reported  a  rash  often  seen  in  their 


GENERAL    SYMPTOMATOLOGY.  121 

epidemic  as  characterized  by  rose-colored  spots  from  one-half  to  two 
inches  in  diameter,  which  faded  to  brown  and  disappeared. 

An  urticarial  rash  was  present  in  6  cases  of  poliomye- 
litis which  were  seen  through  all  the  stages  of  the  disease 
in  the  Cornwall,  England,  epidemic  of  1911.  It  was 
recorded  as  appearing  three  times  on  the  abdomen  and 
once  on  the  abdomen  and  buttocks.  ( Gregor  and  Hopper. ) 

The  multiform  character  of  these  rashes  is  evidence, 
as  Frost  has  reasonably  stated,  that  "no  skin  eruption  can 
be  said  to  be  at  all  characteristic  of  acute  poliomyelitis;" 
yet  the  virus,  acting  with  malignant  energy  on  every  part 
of  the  system,  induces  a  frequent  cutaneous  reaction,  which 
may  simulate  any  of  the  eruptive  diseases.  It  should  be 
borne  in  mind  that  such  rashes  may  occur  in  poliomyelitis, 
to  avoid  confusing  this  disease  with  the  relatively  harmless 
acute  eruptive  fevers. 

Labial  herpes  was  reported  once  in  Wisconsin.  Wick- 
mann  considers  the  condition  not  characteristic.  It  may  be 
coincidental.  Brown,  of  Toronto,  reported  a  skin  eruption 
in  6  consecutive  cases  of  poliomyelitis,  which  followed  the 
same  course  in  each  case.  In  each  of  the  6  cases  a  vesicular 
eruption  was  present  when  the  case  was  first  seen.  The 
rash  was  typical,  being  present  more  or  less  all  over  the 
body.  It  was  papular  and  vesicular,  and  was  present  also 
on  the  lower  extremities,  on  both  anterior  and  posterior 
surfaces.  Sections  through  the  vesicles  show  the  latter 
not  to  be  deep  seated,  as  one  would  imagine  on  palpating 
them,  but,  on  the  contrary,  to  be  only  superficial,  i.e.,  be- 
tween the  Malpighian  and  corneous  layers  of  the  skin. 
Apart  from  the  perivascular  infiltration  no  other  patho- 
logic change  could  be  found.  Smears  and  cultures  from 
the  serum  of  the  vesicles  gave  no  uniform  result. 

Mental  State. — A  feeling  of  grave  apprehension  ac- 
companies the  onset  of  poliomyelitis,  which  has  been  ex- 


122  INFANTILE    PARALYSIS. 

pressed  as  a  feeling  of  impending  danger.  A  farmer  said 
he  felt  as  if  a  cyclone  was  coming,  and  knew  he  must  get 
the  crops  in,  working  into  the  second  day  of  onset  before 
he  gave  up.  Prostration  is  early  and  more  extreme  than 
the  symptoms  would  at  first  indicate.  The  profound  effect 
of  the  virus  acting  on  the  ganglionic  axis  may  provoke 
this  unconditional  surrender,  but  it  may  be  regarded  as  a 
protective  defense  of  nature.  Evidence  favors  the  theory 
that  the  patient  who  surrenders  immediately  lessens  the 
danger  of  paralysis  with  the  recuperative  power  of  rest. 
Ball,  of  Minnesota,  notes,  in  the  series  of  cases  he  investi- 
gated, that  in  the  fatal  cases  the  patients  took  a  varying 
degree  of  exercise  after  the  onset  of  the  disease. 

A  staring  and  frightened  expression  is  often  seen. 
Dakin,  of  Iowa,  considered  this  fades  characteristic 
enough  to  be  called  pathognomonic.  "The  face  appears 
drawn;  the  eyes  sunken,  with  contracted  pupils,  staring 
in  an  unmistakable,  unwinking  terror.  The  expression  of 
fear  has  been  noted  by  the  families  of  patients  in  almost 
every  case."  The  facial  expression  is  noticeably  anxious, 
questioning,  and  gives  a  prematurely  aged  cast  to  the 
countenance. 

Excessive  emotionalism,  hysterical  laughing  and  cry- 
ing, and  change  in  disposition  of  children  have  been  noted 
among  the  early  symptoms.  The  adult  may  be  extremely 
restless,  and  conscious  of  a  vague  anxiety  and  mental 
confusion.  In  this  state  and  driven  by  apprehension,  he 
may  continue  to  automatically  perform  his  work  for  some 
time  after  the  onset.  Mental  confusion  and  determination 
to  remain  at  work  are  shown  in  the  following  case,  with  its 
speedy  lethal  close  :— 

E.,  aged  24;  single;  engineer;  admitted  at  12  noon;  weakness; 
pain  in  right  hip;  inability  to  use  hands;  seven  days  previous  he 
developed  a  sore  throat,  but  worked  until  the  second  day  before 


GENERAL    SYMPTOMATOLOGY.  123 

admission ;  went  to  bed ;  during  these  seven  days  there  was  head- 
ache, pain  in  the  neck;  he  had  vomited,  was  constipated,  and  re- 
ported difficulty  in  thinking.  On  admission  :  pulse  76 ;  temperature 
99°  ;  could  not  hold  a  cup  in  his  hands ;  hands  semiflexed ;  breathing 
abdominal  and  jerky. 

Seven  P.M.  same  day:  respiration  65;  temperature  99°;  pulse 
56.  In  spite  of  extreme  dyspnea,  accessory  muscles  of  respiration 
were  not  in  action.  12  midnight:  cerebration  apparently  clear.  3 
A.M.:  death,  sudden,  of  respiratory  failure.  (Dr.  Colin  Russell, 
Royal  Victorian  Hospital,  Montreal. ) 

Pain. — Pain  is  a  constant  and  early  symptom  of  polio- 
myelitis. Its  usual  occurrence  is  in  the  form  of  basilar  or 
occipital  headache ;  this  may  be  associated  with  an  agoniz- 
ing pain  between  the  shoulders  and  in  the  lumbar  region 
of  the  spine.  In  rare  cases  the  headache  is  at  first  frontal ; 
it  then  localizes  in  the  occiput  or  at  the  cervical  nuchae. 
There  may  be  a  racking  pain  of  the  entire  spine,  which  the 
patient  will  speak  of  as  a  backache.  "I  have  had  back- 
aches before,  but  never  anything  like  this!"  said  a  farmer 
of  50  years,  during  the  onset  of  the  disease  which  proved 
to  be  fatal.  Occipital,  cervical  and  spinal  pains  are  most 
characteristic  of  this  disease,  indicating  their  origin  in  the 
acute  inflammation  of  the  meninges  and  spinal  ganglia. 

.A  I  yalgia  of  a  mild  or  severe  grade  attacks  the  segments 
that  will  shortly  become  paralyzed;  the  myalgia  of  an  ex- 
tremity which  precedes  and  accompanies  the  paralysis  of 
that  area  is  not  to  be  confused  with  the  neuritis  of  great 
nerve-trunks  of  the  so-called  neuritic  types  of  the  disease. 
The  most  careful  handling  of  these  cases  will  cause  agony, 
but  it  seems  possible  to  differentiate  slightly,  i.e.,  that 
pressure  more  than  movement  causes  the  pain.  The 
pressure  pain  is  shown  by  the  child  submitting  to  be  lifted 
to  a  chamber,  but  screaming  with  pain  when  resting  on  it. 
Myalgic  pain  may  be  constant  or  paroxysmal ;  it  invariably 
precedes  the  paralysis  of  the  segment  or  group  of  muscles, 


124  INFANTILE    PARALYSIS. 

and  may  cease  with  the  oncoming  of  the  paralysis ;  it  more 
frequently  remains  for  a  varying  period  after  the  onset 
of  paralysis,  and  may  continue  for  weeks  or  months. 
Wickmann  considers  that  the  extreme  pain  on  movement 
is  due  to  tenderness  and  rigidity  of  the  spinal  column. 

Peripheral  neuritis  may  characterize  another  class  of 
cases,  with  hyperesthesia  and  an  intractable  pain  along  the 
nerve-trunks  and  into  the  posterior  root  ganglia.  These 
cases  do  not  usually  develop  a  paralysis,  but  the  pain  and 
tenderness  of  the  nerve-trunk  may  be  long  continued.  An 
adult  patient  in  whom  the  disease  was  of  fifteen  years' 
standing  had  never  been  free  from  pain  for  a  greater 
period  than  a  day.  Pain  is  a  minor  feature  of  one  class  of 
cases.  The  rapidly  fatal  cases  of  the  bulbar  type  are  very 
quiet,  and  do  not  seem  to  suffer. 

Pain  and  Tenderness. — The  cases  investigated  indicate 
that  pain  or  tenderness  was  present  at  some  stage  in  a 
great  majority  of  cases,  and  it  is  wrell  to  emphasize  its 
importance  among  the  few  really  reliable  early  signs  :— 

Pain  and  tenderness  was  present  in 98  cases. 

Pain  and  tenderness  was  absent  in 25  cases. 

Pain  and  tenderness  was  not  stated  in.  ...      13  cases. 


136  cases. 
Doubtful  or  abortive  cases.  .  10 


146  cases. 

In  this  connection  it  is  interesting  to  note  the  length 
of  time  in  which  the  pain  and  tenderness  lasted,  as  is  shown 
by  the  following  table :— 


GENERAL    SYMPTOMATOLOGY.  125 

One  clay  or  less I  case. 

Two  clays 4  cases. 

Three  clays   4  cases. 

Four  days  9  cases. 

Five  days    i  case. 

One  week   8  cases. 

One  to  two  weeks 8  cases. , 

Two  to  three  weeks 21  cases. 

Three  to  four  weeks 7  cases. 

Four  to  five  weeks 15  cases. 

Five  to  seven  weeks 4  cases. 

Seven  to  eight  weeks i  case. 

Eight  to  nine  weeks 4  cases. 

Still  persisting  7  cases. 

A  fewr  days 4  cases. 

No  pain  or  tenderness 25  cases. 

Not  stated   13  cases. 


136  cases. 
Doubtful  or  abortive  cases.  .  10 


146  cases. 
(Kelly,  State  of  \Yashington.) 

Meningism. — Symptoms  of  meningeal  irritation  are 
rarely  absent  and  in  the  meningeal  type  of  the  disease  are 
marked.  Cervical  pain  and  rigidity,  with  some  retraction 
of  the  head,  are  commonly  seen.  The  spastic  condition  may 
vary  from  a  slight  stiffness  of  the  neck  which  prevents 
Hexing  the  head  on  the  chest,  to  retraction  of  the  head,  or 
an  opisthotonus  of  so  severe  a  degree  that  the  child  lies 
like  a  bent  bow.  The  spasticity  of  the  muscles  may  give 
a  rigid  spine  with  no  flexing  of  same ;  "stiff  as  a  board," 
"stiff  as  a  log  from  head  to  heels."  are  not  exaggerations 
of  the  condition  in  some  of  these  cases.  According  to 
Frost,  this  stiffness  of  the  spine  may  be  due  to  the  pain 
and  only  in  rare  cases  is  due  to  actual  contracture  of  the 
spinal  muscles. 


126  IXFAXT1LE    PARALYSIS. 

Reflc.rcs. — The  patellar  reflex,  when  ascertained,  may 
be  misleading.  It  is  usually  exaggerated  during  the  early 
stage,  and  often  unobserved.  It  is  diminished  or  disap- 
pears prior  to  the  onset  of  the  paralysis  in  the  usual  case. 
As  the  paralysis  of  one  leg  usually  precedes  the  paralysis 
of  its  fellow  by  twenty-four  to  forty-eight  hours,  the  reflex 
may  be  exaggerated  in  the  one  extremity  and  abolished  in 
the  other.  There  may  be  a  persistently  exaggerated 
patellar  reflex  in  paralysis  which  afreets  only  the  upper 
segment.  Spastic  cases  are  unable  to  completely  extend 
the  leg  when  the  thigh  is  flexed  at  a  right  angle;  this  is 
known  as  the  modified  Kernig  test,  and  is  not  usual! \ 
present  until  the  second  day.  Dakin  notes  a  characteristic 
sign  of  stiff  neck.  The  patient,  if  asked  to  touch  his  chin 
and  chest,  will  endeavor  to  do  so  by  opening  the  mouth  and 
depressing  the  lower  jaw,  the  neck  remaining  rigid.  In 
cases  of  cervical  rigidity  with  involvement  of  the  sterno- 
mastoids,  the  patient,  if  told  to  look  at  an  object,  will  roll 
the  eyes  but  make  no  attempt  to  move  his  head. 

The  superficial  and  deep  reflexes  vary  widely  in  re- 
action in  the  different  types  and  stages  of  this  disease,  and 
have  not  been  satisfactorily  classified  in  regard  to  it.  The 
ocular  reflexes  are  not  characteristic,  being  subject  to 
disturbances. 

Meningitis. — As  the  irritant  stage  continues  the  symp- 
toms of  meningeal  involvement  become  more  grave. 
Twitching  and  jerking  of  muscles  and  tremor  appear. 
Convulsive  movements  may  be  manifest  as  a  twisting  of 
torso,  or  true  convulsive  seizures  occur.  The  dismissal  of 
this  subject  with  a  brief  note  that  convulsions  sometimes 
occur  in  childhood  is  as  misleading  as  the  name  infantile 
paralysis.  Convulsions  of  the  most  serious  and  rapidly 
fatal  type  may  occur  at  any  age  and  to  members  of  both 
sexes.  The  virulence  of  the  infection  and  the  area  of  the 


GENERAL    SYMPTOMATOLOGY.  127 

nervous  system  invaded  are  the  factors  that  determine  the 
convulsive  seizure,  and  not  age  nor  sex.  The  only  evidence 
of  the  disease  in  child  or  adult  may  be  a  convulsive  attack 
of  short  duration.  The  attack  may  occur  under  the  most 
misleading  circumstances,  and  may  simulate,  and  be  diag- 
nosed as  any  of  the  diseases  characterized  specifically  by 
convulsive  attacks,  notably  eclampsia,  tetanus,  or  rabies: 
H.  K.,  female,  27;  sudden  onset  August  19,  1906;  fever,  head- 
ache, pains  in  back ;  stiff  neck ;  retracted  head ;  violent  tonic  con- 
traction of  shoulder  muscles,  forearms,  arms  and  hands;  cramp- 
so  painful  as  to  require  chloroform ;  cramps  continued  second  day 
and  night,  opisthotonus.  August  2ist:  the  patient  being  six  months 
pregnant,  eclampsia  was  suspected  and  forced  delivery  undertaken 
successfully.  Cramps  continued,  extending  to  legs ;  dysphagia  and 
aphonia  occurred ;  death  at  6  A.M.,  August  22d.  Conscious  through- 
out; autopsy  revealed  typical  lesions  of  poliomyelitis.  (YVickmann.) 

Confusion,  apathy,  stupor,  and  delirium  are  all  seen, 
and  of  a  transitory  nature  in  most  cases.  Coma  is  rare : — 

September  25,  1908,  E.  T.,  male,  aged  8  years.  Headache,  pain 
in  back  and  neck;  temperature  102°  F.,  comatose  for  several  days; 
no  paralysis;  recovery;  meningeal  type,  no  spinal  symptoms.  (Dr. 
1'xnvles,  Eleva,  Wis.) 

General  Features  of  Acute  Attack — Symptoms. — 198 
cases  give  history  of  fever;  184,  pain  and  tenderness;  117, 
brain  symptoms;  106,  headache;  79,  retraction;  59,  sore 
throat;  24,  apathy;  19,  delirium;  18,  rigidity  of  neck;  13, 
cough;  13,  irritableness;  11,.  restlessness;  n,  unconscious- 
ness; 9,  tired  condition;  8,  rigidity  of  spine;  8,  lassitude; 
7,  strabismus ;  6,  change  of  temperament ;  6,  diaphragmatic 
breathing;  6,  dysphagia;  5,  sweating;  5,  irregular  pulse 
and  respiration;  5,  twitchihgs;  5,  diminished  or  absent 
reflexes;  4,  convulsions;  4, .  nystagmus ;  3,  weakness;  3, 
hyperesthesia;  3,  stupor;  3,  exaggerated  reflexes;  3,  re- 
gurgitation  of  food;  3,  anorexia;  i,  thirst;  I,  anxious  ex- 
pression; i,  tremor;  I,  coma;  I,  tympanites;  I,  insomnia; 
i.  hiccough.  (Sheppard.) 


CHAPTER   VI. 

Symptomatology  of  Special  Types  of  Acute 
Poliomyelitis. 


RECLASSIFICATION  OF  TYPES  OF 
POLIOMYELITIS.* 

I.  The  Arrested  Type.      (Most  frequent.     Abortive: 
old  classification.) 

II.  The  Spinal  Myclitic  Type.     (Flaccid  paralysis.) 

III.  Acute  Ascending  or  Descending  Spinal  Paralysis. 
(  Landry's.      Separation   from  Type   II   arbitrary.      Both 
spinal  origin.) 

IV.  Acute  Bulbar.     (Cranial  nerve  paralysis:    facial, 
auditory,  hypoglossal,  oculomotor. ) 

V.  Encephalic  T\pc. — Polioencephalitis  superior  :    Rn- 
landic  cortex — spastic  hemiplegias.    Frontal  area — mental 
defectives.      Occipital   area — blindness   with   normal   eye- 
grounds. 

Polioencephalitis  inferior:  Acute  bulbar-pontine  type: 
see  above. 

Encephalitis  cerebelli.  The  predominant  acute  ata.via 
type. 

Encephalitis  of  midbrain  and  connections.  .  Iciitc 
tremor. 

Thalamic  encephalitis.  Spastic  para-  or  hemi-  plegias 
associated  with  athetoid  and  choreic  movements  and 
tetany. 

VI.  Mcningitic   Type. — \Yith  or  without  paralysi-. 

1  Modified  from  Wickmann  and  Reginald  Miller,  to  whom  we  are  in- 
debted for  much  recent  knowledge  of  the  disease. 

(128) 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS. 


129 


VII.  Neural  Type. — Acute  multiple  neuritis.    Sciatica. 
Herpes  zoster.    Chorea. 

VIII.  Rapidly  Fatal  Institutional  Disease  Type. 
There  may  be  no  marked  distinction  between  the  types 

of  poliomyelitis;  the  cerebral  type  may  present  symptoms 


Fig.  35. — Paralysis  of  facial  nerve. 

of  spinal  involvement  and  vice  versa;  the  localization  of 
this  disease  may  exhibit  every  caprice  of  selection. 

The  symptom  relationship  between  all  types  is  shown 
most  clearly  during  the  earliest  stages  of  the  disease,  for 
all  types  present  a  similar  onset.  This  symptom  group 
of  onset  is  also  the  clinical  expression  of  the  most  numerous 
class  of  cases,  the  arrested,  formerly  called  the  abortive, 
type  of  this  disease.  Next  in  frequency  appears  the  typical 


130  IXFAXT1LE    PARALYSIS. 

form  of  the  disease  known  as  infantile  paralysis,  charac- 
terized by  a  flaccid  and  regressive  paralysis  of  muscles 
supplied  by  spinal  nerves.  Every  epidemic  also  presents 
cases  where  most  pronounced  symptoms  indicate  menin- 
geal,  pontine,  cerebellar  or  cerebral  involvement.  Some 
hesitation  has  been  shown  in  ascribing  peripheral  neuritis, 
whether  multiple  in  character  or  of  single  neuron  involve- 
ment, to  the  same  cause.  Clinical  evidence  of  such  rela- 
tionship has  accumulated,  and  pathologic  confirmation  is 
confidently  expected. 

I.  THE  ARRESTED  TYPE. 

The  arrested  form  of  poliomyelitis  is  given  first  in  the 
reclassification  of  the  types  of  this  disease  for  the  following 
reasons : — 

1.  The  arrested  form  occurs  more  frequently  than  any 
other  form,  probably  more  often  than  all  others. 

2.  Transmission  of  poliomyelitis  may  be  largely  due 
to  frequent  undiagnosed  cases  of  the  arrested  type. 

The  change  in  the  name  of  this  type  of  poliomyelitis 
from  abortive  to  arrested  w?as  determined  on  for  the  fol- 
lowing reasons : — 

Ignorant  of  the  exact  method  of  transmission  of  this 
disease,  and  lacking  an  antitoxin  for  prophylaxis  and  cure, 
it  is  certain  that  the  epidemic  will  be  checked  in  but  one 
of  two  ways: — 

(a)  By  the  exhaustion  of  the  material  on   which   it 
feeds. 

(b)  By  enlisting  the  intelligent  co-operation  of  the 
public  to  aid  in  the  detection  and  regulation  of  every  focus 
in  which  it  has  located,  but  to  insure  intelligent  attention 
we  should  not  use  misleading  terms.     The  word  abortive 
is  clear  to  the  medical  man,  for  its  adverbial  medical  mean- 
ing is  "tending  to  shorten  in  course/'    To  the  laity  in  this 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS.  131 

connection  the  word  is  dangerously  misleading,  as  its 
common  adverbial  meaning  is  "coming  to  naught." 
Miller's  term  "rudimentary  poliomyelitis"  is  better,  and 
yet  lacks  somewhat  of  precise  definition. 

The  arrested  case  of  poliomyelitis  may  transmit  the 
infection  to  those  with  whom  he  comes  in  contact ;  he  may 
himself  develop  within  a  longer  or  shorter  period  the 
typical  paralytic  form  of  the  disease.  In  other  words  this 
individual  has  the  disease,  but  owing  to  some  fortunate 
bodily  resistance  the  disease  is  arrested.  If  fatigue  or 
exposure  lessens  the  resistance,  the  disease  may  proceed  to 
any  one  of  several  terminations.  For  these  reasons  we 
recommend  and  employ  the  use  of  the  definite  and  true 
descriptive  adverb  arrested  to  the  most  common  type  of 
poliomyelitis,  rather  than  the  misleading  term  abortive. 

The  following  case  is  a  good  example  of  the  arrested 
type  in  which  a  correct  diagnosis  would  have  been  impos- 
sible except  for  association  with  the  frank  case  of  the 
child's  brother: — 

109.  Mild  Anterior  Poliomyelitis. — There  are  several  interest- 
ing points  in  Bullard's  case.  A  child  8  years  old  had  been  thor- 
oughly exposed  to  contagion  from  her  brother,  ill  with  anterior 
poliomyelitis.  The  patient  developed  an  illness  exactly  one  week 
later  than  her  brother.  Her  illness,  although  the  high  temperature 
lasted  but  a  short  time,  was  a  severe  one,  weakening  the  patient, 
who  was  a  vigorous  child,  and  at  the  time  of  the  attack  and  for 
some  time  previously  had  been  in  perfect  health,  so  that  she  was 
in  bed  fourteen  days  and  was  still  weak  at  the  end  of  three  weeks. 
There  was  in  this  attack  no  important  gastrointestinal  disturbance. 
The  patient  was  for  two  days  unwilling  to  eat  and  there  was 
constipation.  Once  when  pressed  to  eat  she  vomited,  but  this  was 
evidently  due  to  a  temporary  condition,  and  was  a  secondary  symp- 
tom. The  general  hypersensitiveness  of  the  nervous  system  was 
very  marked.  The  absence  of  paralysis  is  a  significant  feature. 
The  brother  had  a  typical  case  of  anterior  poliomyelitis  with  paral- 
ysis at  first  of  all  the  limbs;  at  the  present  time  paralysis  of  the 


132 


INFANTILE    PARALYSIS. 


Fig.  36. — Typical  case  of  poliomyelitis,  lateral  view. 

lower    extremities    remains.      (Bullard,    Boston    Mecl.    and    Surg. 
Journal.) 

The  proof  of  the  existence  of  the  arrested  form  of 
poliomyelitis  has  been  summarized  by  Frost  as  follows  :— 

Etiologic  Identity  of  Abortive  (Arrested)  and  Para- 
lytic Forms. — (a)  Cases  presenting  the  same  initial 


SPECIAL   TYPES    OF    ACUTE    POLIOMYELITIS. 


133 


Fig.  37. — Same  as  Fig.  36,  an- 
terior view. 


Fig.  38. — Same  as  Fig.  36,  pos- 
terior view. 


symptoms   as   paralytic   cases   occur  coincidently  in  epi- 
demics and  recover  in  a  short  time  without  paralysis. 

(b)  Every  closely  studied  epidemic  shows  a  gradation 
in  severity  of  nervous  symptoms;  extensive  permanent 
paralysis;  slight  transient  paralysis;  partial  paralysis 


134  1XFAXTJLE    PARALYSIS. 

(paresis) ;  ataxia  without  paralysis;  meningitic  or  neuritic 
symptoms  without  motor  disturbance;  general  infection 
without  distinctive  nervous  symptoms  of  any  kind  (basilar 
headache  and  cervical  tension  always  present).  A  group 
of  cases  showing  all  these  gradations,  occurring  within  a 
circumscribed  area  within  a  short  time,  all  presenting  some- 
what similar  initial  symptoms  seldom  fails  to  convince  the 
observer  of  the  existence  of  abortive  (arrested)  cases  of 
poliomyelitis. 

(c)  The  occasional  occurrence  of  such  cases  during  an 
epidemic  of  poliomyelitis  might  be  put  down  to  merely 
coincidental  prevalence  of  two  or  more  distinct  infections : 
the  frequent,  almost  constant  Occurrence  of  such  cases  in 
intimate  association  with  frank  cases  of  poliomyelitis  can- 
not be  ascribed  to  fortuitous  coincidence. 

(d)  Experiments  have  demonstrated  that  monkeys  in- 
oculated with  poliomyelitis  occasionally  develop  an  abort i re- 
form of  the  infection,  characterized  by  rather  mild  and 
indefinite  symptoms.     Roemer  and  Joseph  have   demon- 
strated in  monkeys  an  immunity  following  such  abortive 
attacks. 

(e)  Netter  and  Levaditi  have  shown  that  the  serum 
of  a  child  recently  recovered  from  an  abortive  attack  (ar- 
rested  type)    was   capable  of   neutralizing  the  virus   of 
poliomyelitis.     It  is,  therefore,  well  established  by  clinical 
and  experimental  evidence  that  the  infection  of  acute  an- 
terior poliomyelitis  may  cause  slight  illness  without  definite 
motor  symptoms. 

Frequency  of  the  Arrested  Form  of  Poliomyelitis. — 
Recent  extensive  study  of  epidemics  of  poliomyelitis  in 
small  communities  have  made  it  evident  that  the  arrested 
form  of  the  disease  occurs  as  frequently  as  any  other  type, 
and  perhaps  more  often  than  all  other  types  taken  together. 
In  the  careful  investigation  of  the  following  epidemic  in  a 


SPECIAL   TYPES    OF    ACUTE    POLIOMYELITIS.  135 

school  district  in  Iowa,  5  cases  out  of  every  6  were  of  the 
arrested  form,  or  25  of  the  30  cases  seen. 

An  epidemic  occurred  in  May,  1910,  in  a  rural  school  dis- 
trict in  Hancock  County,  Iowa.  Within  a  period  of  three  weeks 
30  cases  of  illness  of  the  same  general  type  occurred  among 
8  of  the  12  families  in  attendance  at  this  school;  5  cases  re- 
sulting in  typical  definite  paralysis  were  undoubtedly  frank  polio- 
myelitis. The  remaining  25  may  be  considered,  in  all  probability, 
abortive  (arrested)  attacks  of  the  same  infection.  The  most 
common  symptoms  in  this  group  were  severe  headache,  pains  in  the 
Iffcibs  and  back,  stiffness  of  neck  and  spine,  and  nausea  and  con- 
stipation. (Frost,  Public  Health  Bulletin.) 

Of  952  cases  which  occurred  in  Norway  in  1905,  358 
were  of  the  abortive  type.  (  Harbitz.) 

It  would  seem  that  the  closer  the  observation  in  any 
given  epidemic,  the  greater  are  the  number  of  cases  of  the 
arrested  type  described.  In  "Wickmann's  study  of  the  epi- 
demic in  Sweden  in  1905,  he  reported  157  arrested  cases 
among  1025  cases  he  investigated, — 15  per  cent.  He  con- 
sidered that  the  proportion  of  arrested  cases  was  much 
greater  than  this,  and  was  able  to  verify  his  belief  in  the 
smaller  communities,  where  all  cases  could  be  more  easily 
traced.  He  found : — 

Arrested       Frank 
Total.         cases.          cases.       Per  cent. 

Trastena 49  23  26  46 

Atvidaberg    31  n  20  35 

Smedjeback   50  28  22  56 

In  the  epidemic  of  700  cases  which  swept  the  Island  of 
Xauru  in  January,  1910,  only  50  cases  had  any  paralysis 
remaining  at  the  end  of  three  months,  and  Miiller  reported 
that  many  others  had  only  a  slight  paresis  lasting  two 
weeks  or  less,  while  many  had  no  paralysis  whatever. 

These  cases  are  often  unrecognized.  I  am  reminded  of 
the  reply  of  a  mother  whom  I  saw  in  my  daily  round  during 


136  1XFAXTILE    PARALYSIS. 

the  Eau  Claire  epidemic.  The  mother  was  holding  a  lusty 
boy  in  her  arms,  and  to  the  question  if  he  was  ill,  said: 
"Xo,  he  ain't  sick,  he  had  a  high  fever  last  night,  and  this 
morning  he  can't  stand  alone,  but  he  ain't  sick."  Those 
fleet  symptoms  marked  the  only  disturbance  of  the  2-year- 
old. 

The  motor  weakness  of  a  small  child  in  arms  could  ap- 
pear only  as  an  unnatural  limpness.  The  arrested  case  may 
terminate  fatally  as  in  the  one  recorded : — 

Case  7.  Child  2  years  old.  One  of  twins.  (Twin  polioe^- 
cephalitis  with  coma  and  paralysis  of  right  upper  and  lower  extremi- 
ties.) Onset  four  days  after  onset  in  twin.  Vomited,  fever,  stupor, 
some  cervical  rigidity,  ataxia,  no1  palsy.  Temperature  normal  on 
eighth  day.  Child  up  at  end  of  second  week;  case  considered 
abortive  and  was  about  to  be  discharged  when  "she  suddenly  de- 
veloped convulsions  and  died."  (Sophian.) 

Symptoms  of  the  -Irrcstcd  Type. — The  symptoms  of 
onset  of  poliomyelitis  are  the  symptoms  of  the  arrested 
form  of  the  disease.  These  symptoms  usually  occur  in  a 
somewhat  modified  form,  but  they  may  be  as  severe  and 
prolonged  as  a  case  of  the  paralytic  type.  Some  symptoms 
are  apt  to  be  more  prominent  than  others,  and  cases  of  the 
same  type  usually  occur  in  groups.  The  arrested  forms  in 
a  family  which  develops  one  or  more  cases  of  true  paralysis 
may  all  suffer  from  a  neurasthenic  hyperexcitability  or 
languor ;  the  members  of  such  a  group  may  all  be  attacked 
with  nausea  or  vomiting,  or  diarrhea,  or  both.  Meningism 
may  mark  the  onset  in  another  community.  The  symptoms 
of  a  general  infection,  some  degree  of  gastric  disturbance 
and  meningism,  are  present  in  all  these  cases.  Constipa- 
tion with  a  preceding  diarrhea  is  the  rule. 

A  change  in  disposition  is  the  most  common  symptom ; 
basilar  headache  with  cervical  tension  is  usually  present. 
There  is  a  rise  in  temperature,  which  is  usually  brief,  lim- 


SPECIAL    TYPES    OF    ACUTE    POLIOMYELITIS.  137 

ited  to  a  few  hours ;  but  it  has  lasted  into  the  third  day.  The 
pulse  rate  is  increased.  There  is  a  feeling  of  marked 
languor,  or  one  of  anxiety  and  restlessness.  Anorexia  is 
usual,  and  there  may  be  nausea  and  vomiting.  There  is 
also  some  degree  of  pain.  This  may  be  a  myalgic  pain  of 
the  back  or  extremities,  and  is  associated  with  tenderness. 


Fig.  39. — Poliomyelitis  involving  the  neck.     Note  forward 
"head-drop."     (Sheffield.} 

The  spine  is  usually  tender  its  entire  extent.  Tremor,  in- 
co-ordination,  an  ataxia  manifesting  itself  as  an  apparent 
clumsiness  may  or  may  not  be  noted.  When  a  frank  dis- 
turbance of  motion  is  apparent,  or  meningitic  twitchings 
or  convulsions  occur,  the  case  does  not  belong  to  the  ar- 
rested type. 

Cases  of  the  arrested  type  will  be  found  out  playing  on 
the  first,  second,  or  third  day,  but  walking  with  their  heads 


138  INFANTILE    PARALYSIS. 

well  back  and  a  somewhat  stiff  and  awkward  gait;  a  leg 
may  occasionally  give  way,  causing  the  child  to  fall. 
(Anderson.) 

The  diagnosis  of  the  arrested  type  of  the  disease  is  not 
difficult  during  an  epidemic,  when  the  association  with 
frank  cases  is  apparent.  AYithout  this  association,  but 
during  the  present  pandemic,  it  would  be  well  to  regard 
with  suspicion  cases  of  basilar  headache,  with  cervical  ten- 
sion and  tender  spines,  which  at  the  same  time  present  an 
elevated  temperature. 

II.  THE  SPINAL  MYELITIC  TYPE. 

Case  (typical,  mild).  D.  E.,  3  years;  male  (physician's  son). 
Onset :  temperature  104°  F. ;  twitching,  but  no  convulsions ;  de- 
lirium; stupor;  pain;  paralysis  of  right  leg;  knee-jerk  absent  on  the 
affected  side,  normal  on  left;  slight  atrophy;  recovery.  (Dr.  A.  \Y. 
Myers,  Milwaukee,  August  10,  1908.) 

Case  (typical,  severe).  D.  H.,  female,  2  years.  Onset:  tem- 
perature 103°  F. ;  pain;  vomiting;  delirium;  paralysis  of  both  lower 
extremities,  left  upper  extremity,  muscles  of  back  and  neck ;  remains 
same.  (Dr.  M.  W.  Dvorak,  La  Crosse,  Sept.  16,  1908.) 

The  characteristic  of  the  spinal  myelitic  type  is  the 
development  of  a  flaccid  motor  paralysis  of  the  muscles 
supplied  by  spinal  nerves.  The  distribution  of  the  paralysis 
of  the  muscles  usually  follows  their  segmental  relation  in 
the  cord.  The  usual  involvement  of  the  lumbar  enlarge- 
ment and  the  less  frequent  destructive  invasion  of  the 
cervical  enlargement  result  in  the  paralysis  of  the  lower 
and,  less  commonly,  of  the  upper  extremities.  As  a  rule. 
the  paralysis  is  more  extensive  than  persistent,  a  regression 
taking  place  after  the  height  of  the  paralysis  has  been  at- 
tained. The  severity  of  the  onset  is  no  certain  indication 
of  the  degree  of  paralysis  which  may  obtain. 

The  spinal  myelitic  type  is  most  apt  to  present  an  aura 
of  onset;  this  aura  usually  occurs  from  two  davs  to  a  week 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS.  139 

before  the  onset  and  will  take  the  form  of  a  stumbling  gait, 
unusual  falls  in  a  hitherto  sure-footed  child,  and  tremor, 
inco-ordination,  and  ataxia  in  the  adult. 

The  onset  is  sudden,  with  fever  and  general  indisposi- 
tion; insufficient  observation  is  responsible  for  the  state- 
ment that  cases  of  paralysis  occur  without  preceding  initial 


Fig.  40. — Paralysis  of  right  leg,  left  arm,  and  face,  with  pain  and  hyper- 
esthesia.     (X.  Y.  Hospital  for  Deformities  and  Joint  Diseases.) 

symptoms.  Sometimes  the  attack  develops  in  two  distinct 
periods  with  a  pause  between,  during  which  the  patient 
recovers,  and  then  suffers  a  relapse  and  the  paralysis  de- 
clares its  presence. 

The  paralysis  usually  develops  from  the  second  to  the 
fifth  day  after  the  onset.  It  may  be  delayed  for  a  longer 
period,  two,  three,  four  and  six  weeks'  delay  having  been 
reported.  It  is  progressive  in  development.  If  the  lower 
extremities  are  attacked,  paralysis  of  one  develops  twenty- 


140  INFANTILE    PARALYSIS. 

four  to  forty-eight  hours  before  the  other.  The  lower  limbs 
are  usually  involved  before  the  arms,  although  the  reverse 
may  occur.  If  the  paralysis  is  not  suspected,  it  may  have 
fully  developed  before  it  is  discovered;  this  is  not  inf re- 


Fig.  41. — Paralysis  of  muscles  of  left  abdominal  wall,  with  hernia. 
(N.  Y.  Hospital  for  Deformities  and  Joint  Diseases.) 

quently  the  case  with  young  children,  and  gives  rise  to  the 
statement  that  complete  paralysis  develops  suddenly. 

With  the  progressive  development  of  the  paralysis,  the 
symptoms  of  onset  diminish  in  intensity  and  usually  by 
crisis.  The  greatly  accelerated  pulse  slows  to  near  the 
normal,  or  may  show  -a  bradycardia.  The  febrile  tempera- 
ture drops  to  within  one  degree  of  normal.  The  respira- 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS.  141 

tions  also  become  less  frequent,  unless  there  is  an  oncoming 
paralysis  of  the  respiratory  muscles. 

The  symptom  groups  which  originate  in  meningeal  irri- 
tation or  in  invasion  of  sensory  fiber  tract  may  show  some 
remission,  but  usually  become  more  profound  until  regres- 
sion of  the  paralysis  is  established.  Pain  and  tenderness 
of  the  spine  are  enhanced,  and  great  hyperesthesia  develops 
in  the  affected  extremities.  Delayed  urination  or  retention 
occurs,  due  to  paretic  inhibition  of  the  bladder  wall;  the 
paretic  torpidity  of  the  bowels  results  in  coprostasis. 

Considered  as  a  whole,  however,  the  symptoms  of  onset 
moderate  to  a  marked  degree  or  disappear  with  the  on- 
coming of  the  paralysis. 

Progression  of  the  paralysis  to  its  maximum  limit  and 
extent  may  occupy  from  two  days  to  a  week  or  more. 
There  may  be  a  paretic  condition  only,  with  quick  return 
to  normal  function  of  the  involved  group  of  muscles ;  there 
may  be  paralysis  of  apparently  severe  degree  involving  all 
four  extremities,  and  a  subsequent  recession  of  the  'paral- 
ysis, with  no  permanent  damage  to  more  than  one  extremity 
or  muscle  group.  A  recession  of  the  paralysis  is  usual, 
but  a  certain  number  of  cases  show  no  regression,  and  a 
subsequent  atrophy  of  the  involved  muscle  groups  occurs. 

The  muscle  groups  least  involved  and  those  last  in- 
volved usually  recover  first;  the  regression  may  leave  but 
one  token  of  paralytic  attack,  the  ptosis  of  an  eyelid,  or 
the  involvement  of  a  single  muscle  group,  leaving  a  wry- 
neck or  drop-foot. 

Distribution  of  Paralysis. — The  distribution  of  the 
paralysis  in  the  cases  which  occurred  in  the  State  of  Massa- 
chusetts in  1910  has  been  tabulated  by  Drs.  Lovett  and 
Sheppard : — 


142  INFANTILE    PARALYSIS. 

DISTKIIU'TION  OF  KARLY  PARALYSIS. 

Cases. 

One  leg  only 145 

Both  legs  only   146 

One  arm  only 44 

Both  arms  only 12 

One  arm  and  leg,  same  side 50 

One  arm  and  leg,  opposite  sides 18 

Both  legs  and  one  arm 32 

Both  arms  and  one  leg 8 

Both  arms  and  both  legs  . 51 

Ataxia    (transitory  )    7 

Back   7<> 

Abdomen 38 

Xeck ' 13 

Respiration  30 

Deglutition    12 

Intercostal    i 

Face 7 

Right  face 31 

Left  face 24 

Strabismus    .  2 


759 
(Lovett  and  Sheppard,  Bulletin  Mass.  Board  of  Health.) 

The  lower  limbs  are  most  often  paralyzed,  and  both 
legs  are  usually  affected  during  the  progression  of  the 
paralysis;  the  residual  paralysis  is  usually  confined  to  one 
leg.  In  our  series  of  cases  paralysis  of  both  legs  was 
reported  (49  cases)  to  be  about  twice  as  frequent  as  paral- 
ysis of  one  leg  (26  cases).  With  definite  paralysis  of  one 
leg,  examination  of  its  fellow  will  usually  demonstrate  a 
marked  exaggeration  of  the  knee-jerk,  which  would  imply 
some  degree  of  involvement  of  the  quadriceps  extensor  at 
least. 

The  lower  limbs  are  affected  much  more  often  than  the 
anus.  Frost  considers  this  ratio  to  be  as  2  to  i.  In  Wis- 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS.  143 

cousin  it  was  3  to  i  during  the  acute  stage.  A  severe  case 
of  the  spinal  type  may  present  a  paralysis  of  both  legs  and 
a  spastic  condition  of  the  trunk  and  arms,  which  are  further 
immobilized  by  pain  during  the  acute  stage,  but  the  resid- 
ual paralysis  in  these  eases  frequently  involves  the  legs 


Fig.  42. — Most  common  type  of  spinal  form  of  poliomyelitis. 
Paralysis,  atrophy,  and  shortening  of  one  lower  extremity.  (N.  Y. 
Hospital  for  Deformities  and  Joint  Diseases.) 

only.  The  cases  presenting  residual  paralysis  of  leg  or 
arm  only  would  give  a  ratio  of  8  to  10  of  the  lower-segment 
group  to  i  of  the  upper-segment  group. 

A  paralysis  of  any  or  all  extremities  may  occur,  or  of 
any  combination  of  these  four  members  of  the  body.     This 


144 


INFANTILE    PARALYSIS. 


paralysis  is  rarely  total  at  the  maximum ;  the  toes  or  fingers 
can  usually  be  voluntarily  flexed.  Regression  of  the  paral- 
ysis usually  leaves  a  permanent  lesion  of  only  certain 
muscle  groups :  the  great  quadriceps  extensor  and  peroneal 
group  of  the  legs ;  the  shoulder  and  upper-arm  group  of  the 
arms.  The  flexors  of  the  leg  are  rarely  involved,  and  ex- 


Fig.  43. — Spinal  type.    Actual  shortening  one  and  one-half  inches  in  two 
years.     (N.  Y.  Hospital  for  Deformities  and  Joint  Diseases.) 

tensors  of  the  arm  usually  escape.  The  atrophy  which 
follows  rapidly  often  brings  to  notice  a  hitherto  unsus- 
pected muscle  involvement;  the  buttock  muscles  of  the 
affected  leg  wither,  and  a  quickly  established  scoliosis  is 
found,  due  to  atrophy  of  the  hip,  side  and  back,  as  well  as 
to  the  effort  of  the  child  to  stand  straight  on  the  affected 
leg. 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS. 


145 


In  the  clinic,  drawn  largely  from  the  east  side  of  Man- 
hattan, there  are  numerous  cases  of  scoliosis  due  to  the 
paralysis  of  the  erector  spinae  segments,  with  paralysis  and 
atrophy  of  the  serrati  and  latissimus  dorsi.  The  lesion 
is  usually  unilateral :  in  24  of  25  such  cases  seen  at  the 


Fig.  44. — Paralysis,  atrophy,  sco- 
liosis, and  rotation  following  acute 
poliomyelitis.  (X.  Y.  Hospital  for 
Deformities  and  Joint  Diseases.) 


Fig.  45. — Posterior  view  of  Fig.  44. 


clinic  of  the  Hospital  for  Deformities  and  Joint  Diseases, 


the  right  side  was  affected. 


The  postparalytic  atrophy  of  these  muscles  of  the  back 
and  one  side  is  extreme.  The  resulting  distortions  are 
various,  depending  largely  on  the  contraction  of  the  cor- 
responding muscles  of  the  opposite  side. 


10 


146  IXFAXTILE    PARALYSIS. 

Radiograms  of  these  children  show  not  only  every 
degree  of  scoliosis,  but  a  rotation  of  the  bodies  of  verte- 
brae, from  the  pull  of  unopposed  muscles. 

In  the  Massachusetts  epidemic  of  1909,  of  which  613 
cases  were  investigated,  there  was  paralysis  of  the  back, 
.^3  times;  of  the  abdomen,  37  times.  In  Xew  York  State. 
1910,  of  226  cases,  the  back  was  affected  34  times,  the 
abdomen  20  times.  Xo  comment  is  made,  however,  in 
those  cases  of  extreme  distortion  resulting.  I  am  inclined 
to  attribute  the  extreme  cases  seen  at  the  Xew  York  City 
clinics  to  be  the  result  of  infantile  paralysis,  plus  the  con- 
ditions of  tenement-house  life. 

Paralysis  of  the  extremities  is  more  common,  but  less 
serious  than,  paralysis  of  the  muscles  of  the  torso.  The 
gravity  of  the  condition  increases  as  the  paralysis  ap- 
proaches the  chest  muscles.  Some  paresis  of  the  involun- 
tary muscles  of  the  bowels  is  indicated  by  the  constant 
constipation,  to  which  is  added,  infrequently,  a  paralysis 
of  the  abdominal  musculature.  The  meteorism  attending 
paresis  of  the  bowel  pushes  out  the  relaxed  abdominal  wall 
in  huge  hernias ;  three  of  these  great  protrusions  are  some- 
times seen  on  a  single  case.  These  paralytic  hernias  are 
usually  temporary,  but  may  remain.  AYhen  the  paralysis 
is  confined  to  one-half  of  the  abdominal  wall  the  unopposed 
muscles  of  the  other  side  will  draw  the  navel  away  from 
the  hernia.  The  abdomen  may  be  uniformly  dome-shaped, 
with  bulging  during  crying  or  coughing. 

Paresis  of  the  bladder  is  frequent,  resulting  in  retenti*  >n. 
Paresis  of  the  urinary  sphincter  is  less  frequent,  and  in- 
continence may  be  the  result  of  distention  and  overflow. 
Control  of  both  urinary  and  anal  sphincter  is  wholly  IMSI. 
however,  in  a  small  number  of  cases. 

Diaphragmatic  paralysis  is  serious,  but  not  of  necessity 
fatal.  It  is  indicated  by  a  reversal  of  the  abdominal  respira- 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS.  147 

tory  excursion,  which  now  retracts  on  inspiration,  and 
protrudes  the  abdominal,  walls  on  expiration.  When  com- 
bined with  paralysis  of  the  intercostal  muscles  death  from 
respiratory  failure  ensues.  Paralysis  may  affect  the 
muscles  of  one-half  of  the  chest  only,  which  will  be  com- 
pletely immobilized,  while  the  respiratory  excursion  may 
be  seen  on  the  unparalyzed  side.  When  the  intercostals 
of  both  sides  are  involved  the  chest  will  remain  immobile, 
and  breathing  will  be  purely  abdominal  in  type. 

X.  K.,  male,  n  years.  Onset:  fever  103°  F.,  weakness,  pain 
in  shoulders,  stiff  neck ;  paralysis,  two  lower,  two  upper,  diaphragm 
and  throat  muscles;  recovery  with  some  remaining  paralysis  of 
diaphragm.  (Dr.  Riley,  Elk  Mound,  Wisconsin,  September  6,  1908.) 

TIME  OF  APPEARANCE  OF  PARALYSIS  AFTER  ONSET  OF  FEVER. 

Cases. 

Same  day 20 

One  day  31 

Two  days 40 

Three  days   34 

Four  days 15 

Five  days   1 1 

Six  days 1 1 

Seven  days  14 

Eight  days  4 

Xine  days   2 

Ten  days 2 

Eleven  days  2 

Twelve  days 4 

Thirteen  days I 

Fourteen  days i 

Two  to  three  weeks 5 

Three  to  four  weeks i 

Four  to  five  weeks i 

Eight  weeks   i 

200 
(Lovett  and  Sheppard.) 


•  148  INFANTILE    PARALYSIS. 

Spontaneous  Regression. — As  a  rule  the  paralysis  is 
more  extensive  than  persistent.  When  the  paralysis 
reaches  the  maximum,  regression  is  soon  established  in  all 
but  extremely  serious  or  fatal  cases.  This  improvement 
may  be  rapid  for  some  days  or  weeks.  The  regeneration 
is  not  so  rapid,  but  is  continued  over  a  long  period  of  time. 
The  spontaneous  improvement  in  these  cases  is  sometimes 
remarkable. 

TRANSVERSE  MYELITIS. 

A  variation  in  the  usual  spinal  type  of  poliomyelitis  is 
found  when  the  involvement  is  distinctly  segmented  in 
localization  and  extends  across  a  section  of  the  dorsal  or 
lumbar  level  invaded.  Harbitz  and  Scheel  demonstrated 
the  pathologic  lesion  in  a  case  of  poliomyelitis  which  came 
to  autopsy,  and  state:  "We  found  the  process  affecting 
most  the  tenth  and  eleventh  dorsal  segments  as  a  trans- 
verse myelitis  with  its  symptoms,  but  with  the  usual  diffu- 
sion of  the  process  elsewhere." 

Cases  of  transverse  myelitic  form  of  acute  poliomyelitis 
have  been  reported  by  Williams,  of  Washington,  and 
Skoog,  of  Missouri;  an  abstract  of  Dr.  Skoog's  very  full 
report  is  included : — 

F.  G.,  schoolgirl,  white,  aged  13.  Excellent  health  prior  to  date 
of  onset;  Nov.  2,  1909,  pain  in  left  lumbar  and  pleural  region,  fol- 
lowing day  along  entire  spine  with  backache,  headache,  legache,  and 
pain  in  abdomen.  These  symptoms  continued  for  four  days  with 
temperature  to  103.2°  F.,  respiration  24,  pulse  to  120.  Constipation 
continuous,  and  retention  of  urine  after  third  day.  Patient  wakened 
on  third  day  by  a  sensation  of  numbness  which  began  in  both  feet 
and  crept  rapidly  upward  to  lower  chest.  The  right  and  left  sides 
were  equally  involved.  A  mild  delirium  was  observed  on  the  third, 
fourth,  and  fifth  days. 

Examination  on  the  Sixth  Day  of  Illness. — Mental  depression 
slight,  but  coherent  replies  to  all  questions;  normal  function  of 
cranial  nerves;  motor  power  in  neck  group  and  upper  extremities 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS.  149 

normal.  There  was  an  absolute  flaccid  paralysis  of  all  muscles  in  the 
lower  extremities,  not  a  trace  of  movement  being  detected  at  hip-, 
knee-,  ankle-,  or  toe-  joints.  The  abdominal  muscles  showed  much 
weakness.  Complete  retention  of  urine  and  feces.  Reflexes  of  head 
and  upper  extremities  normal.  Xo  epigastric,  abdominal,  gluteal, 
patellar,  or  ankle  reflexes  could  be  elicited.  Plantar  stimulation 
produced  no  response.  There  was  a  complete  sensory  paralysis  of 
the  area  supplied  by  the  eighth  dorsal  cord  segment  and  below,  there 
being  no  response  to  touch,  cotton,  pinpricks,  thermal  test,  deep  pres- 
sure or  vibration  stimuli  in  the  lower  extremities.  Movements  of 
the  thorax  involving  all  the  upper  dorsal  vertebrae  caused  intense 
pain,  but  there  was  no  true  hyperalgesia  nor  hyperesthesia  from  the 
seventh  dorsal  area  upward.  Sense  of  position  was  entirely  absent 
at  toe,  ankle-  and  knee-  joints,  but  feebly  present  at  hips,  the  right 
equal  to  the  left.  Course:  exhaustion,  cystitis,  bed-sores,  and 
other  complications,  with  emaciation  reaching  a  severe  degree,  and 
death  February  22,  1910.  Full  mental  faculties  were  retained  until 
forty-eight  hours  before  the  exitus,  when  they  dulled  into  coma. 
The  muscles  of  the  lower  extremities  remained  functionless,  flaccid, 
and  became  rapidly  atrophic.  A  feeble  right  and  left  toe  extension 
sign  could  be  demonstrated  in  the  third  week,  but  not  two  weeks 
later.  Xo  change  appeared  in  the  findings  as  to  deep  reflexes. 
Trophic  disturbances  developed  early  and  edema  of  the  lower  ex- 
tremities during  the  last  month.  There  was  continuous  pyrexia  to 
104°  F.  During  the  early  period  of  the  illness,  with  considerable 
caution,  a  diagnosis  of  acute  epidemic  poliomyelitis  with  a  trans- 
verse myelitis  was  made.  The  subsequent  course  of  the  case  and 
the  autopsy  supported  this  diagnosis. 

CARDIAC  PAIN  AND  CARDIAC  INVOLVEMENT. 

Potpeschnigg,  of  Stuttgart,  states  that  in  some  in- 
stances sharp  pains  in  the  breast  were  among  the  first 
symptoms  of  onset  noted.  It  may  very  well  be  the  case 
that  the  nerves  supplying  the  respiratory  muscles,  which 
later  develop  a  fatal  paralysis,  exhibit  an  early  neuritis.  A 
second  possible  explanation  is  involvement  of  cardiac 
nerve-filaments;  the  alarming  rise  in  the  pulse  rate,  which 
is  a  very  constant  factor  of  the  onset,  indicates  that  there 


150  INFANTILE   PARALYSIS. 

is  marked  cardiac  involvement.  The  following  cases  of 
endocarditis  in  previously  healthy  children  occurring 
svnchronously  with  acute  poliomyelitis  were  personally 
communicated  to  the  writer  by  Dr.  Ben].  Ayres,  of 
Brooklyn  :— 

ENDOCARDITIS  AND  ACUTE  POLIOMYELITIS,  WITH 
SYNCHRONOUS  OCCURRENCE. 

Case  i.  F.  \Y.,  female.  11  years.  Onset  July  8.  1912.  Gradual. 
Paralysis  appearing  July  i2th.  Maximum  paralysis  in  right  arm  and 
leg.  Residual  paralysis  slight,  February  15,  1913.  Atrophy  im- 
proving under  massage  and  electricity ;  history  of  exposure,  un- 
known ;  insect  bites,  none. 

Heart  findings:  endocarditis  from  onset,  improved  after  three 
months'  treatment.  Murmur  and  slightly  accelerated,  irregular 
action  at  present. 

Case  2.  G.  B.,  female,  9  years.  Onset  March  I,  1912;  sudden 
in  character;  paralysis  date  after  onset.  8  days;  maximum  extent, 
left  leg  and  arm,  muscles  of  neck,  and  cervical  region;  paralysis 
residual,  none  after  six  months ;  atrophy  slight.  History  of  ex- 
posure, unknown. 

Heart  findings :  endocarditis,  onset  on  eighth  day.  Murmur 
and  accelerated,  irregular  pulse  still  persist.  (Ayres.) 

III.  THE  ACUTE  ASCENDING  OR  RAPIDLY  PROGRESSIVE 
FORM.     (LANDRY'S.) 

Those  cases  of  acute  poliomyelitis  in  which  there  is 
progressive  involvement  of  the  cord  present  characteristic 
symptoms  which  align  them  clinically  in  a  separate  group- 
ing. The  progression  of  the  paralysis  is  usually  from  the 
lower  extremities  upward,  and  death  ensues,  when  both 
diaphragm  and  intercostal  muscles  are  involved,  from 
paralysis  of  respiration.  The  cases  usually  succumb  during 
the  first  week,  and  some  cases  are  incredibly  swift  in  termi- 
nation. Of  3  fatal  cases  of  the  acute  respiratory  type  seen 
by  the  writer,  a  girl  5  years  of  age,  whose  onset  occurred 


SPECIAL   TYPES    OF    ACLTE    POLIOMYELITIS.  151 

after  some  well-marked  prodromes,  at  breakfast,  died  be- 
tween 5  and  6  o'clock  of  the  same  day ;  2  brothers,  aged  2 
and  /  years,  taken  ill  on  Tuesday  and  Thursday,  died  of 
respiratory  failure  the  following  Sunday  afternonn. 

A  classical  picture  of  this  form  of  poliomyelitis  is  given 
by  Draper,  Peabody  and  Dochez  in  their  recent  mono- 
graph, a  part  of  which  is  abstracted:— 

"The  typical  clinical  picture  i>  that  of  one  with  a  clear,  alert 
sensorium,  righting  for  every  breath  until  he  is  literally  suffocated. 
In  fatal  cases  there  is  usually  a  pause  after  the  acute  onset  of  the 
paralysis.  There  may  be  one  or  two  days  without  any  definite 
increase  in  paralysis,  but  it  is  noticeable  that  the  children  are  not 
doing  so  well  as  those  that  will  eventually  recover.  Often  the 
respiration  is  more  rapid  and  a  trifle  more  difficult  than  the  degree 
•of  paralysis  warrants.  They  are  frequently  unusually  excitable  and 
irritable.  Then  the  paralysis  may  begin  to  increase.  A  laryngeal 
disturbance  with  hoarseness,  aphonia,  or  difficulty  in  swallowing 
may  be  the  first  evidence  of  the  spreading  lesion.  If  the  inter- 
i'i  >-tals  are  still  active  the  movement  of  the  chest  becomes  less 
marked.  If  the  diaphragm  has  hitherto  been  intact,  its  movement. 
as  represented  by  the  abdominal  wall,  becomes  weaker,  or  there  is 
an  asymmetric  movement  suggesting  a  paralysis  of  one  side  of  the 
diaphragm.  The  ala?  nasi  dilate  with  inspiration,  and  the  accessory 
muscles  of  respiration  of  the  neck  come  into  play.  As  the  diaphragm 
weakens,  the  neck  muscles  become  more  and  more  prominent  until 
it  seems  as  if  the  whole  work  of  breathing  depended  on  them.  The 
head  is  thrown  back,  and  with  every  breath  the  lower  jaw  is  pushed 
downward  and  forward  in  an  attempt  to  get  air.  Meanwhile  the 
lungs  may  have  remained  perfectly  clear  until  the  very  end,  or  a 
few  hours  before  death  coarse,  moist  rales  may  accumulate,  an 
edema  suggesting  vasomotor  paralysis.  Heart  sounds  have  been 
audible  for  as  much  as  five  minutes  after  breathing  stopped. 
Several  times  a  characteristic  arrhythmia  has  set  in  for  the  last 
few  hours  of  life.  It  is  interesting  that  in  one  case,  in  association 
with  the  institution  of  artificial  respiration  and  a  lessening  of 
cyanosis,  the  irregularity  of  heart  action  completely  disappeared. 

"\Yith  the  onset  of  respiratory  difficulty,  it  seems  as  if  the 
children  were  suddenly  awakened  and  made  to  realize  the  struggle 


152  1. \FAXTILE    PARALYSIS. 

before  them.  One  sees  a  sleepy  baby  become  all  at  once  wide  awake, 
high  strung,  alert  to  the  matter  in  hand,  and  this  is,  breathing.  The 
whole  mind  and  body  appeared  to  be  concentrated  on  respiration. 
The  child  gives  the  impression  of  one  who  has  a  fight  on  his  hands 
and  knows  perfectly  well  how  to  manage  it.  Instinctively  he 
husbands  his  strength,  refuses  food,  and  speaks  when  necessary 
with  few  words.  One  little  child,  aged  4,  unable  to  move,  but  with 
a  mind  that  seemed  to  take  in  the  whole  situation,  said  abruptly  to 
the  nurse,  between  her  hard-taken  breaths,  'Turn  me  over.'  'Scratch 
my  nostril;'  and  then,  to  the  doctor,  'Let  me  alone,  doctor.'  'Don't 
touch  my  chest.' 

"Pressure  on  the  chest,  tight  neck-bands,  anything  that  ob- 
structs easy  respiration  is  immediately  resented.  The  child  is 
nervous,  fearful,  and  dreads  being  left  alone.  He  often  shows  an 
instinctive  appreciation  for  the  specially  efficient  nurse.  The  mouth 
becomes  filled  with  frothy  saliva  which  the  child  is  unable  to  swallow, 
so  he  collects  it  between  his  lips  and  waits  for  the  nurse  to  wipe  it 
away.  The  pallor  is  distinctive,  the  lips  blue,  cyanosis  absent,  and 
sweating  profuse.  The  mind  becomes  dull,  unconsciousness  follows, 
and  an  hour  or  more  later  respiration  cease-.' 

As  a  typical  case  may  be  considered  the  following:— 

\\erner  A.,  14  years.  For  three  days,  fever  and  severe  con- 
stipation. On  third  day,  paralysis  of  both  legs,  next  day  ascending 
to  abdominal  and  thoracic  muscles.  On  the  fifth  day,  death  from 
respiratory  failure.  (Kelly,  Seattle.) 

Case  of  Ascending  TY/V,  wth  Death  on  Fortieth  Day. — E.  F.. 
male,  18  months.  Onset,  May  26,  1908.  Fever,  restlessness,  de- 
lirium; pain  on  moving  limbs;  temperature  when  first  seen  (after 
paralysis  began)  100.5°  F.,  late,  thirty-eighth  day,  108.5°  to  IIO°  F., 
per  rectum.  Rash :  bright  first  two  days.  Paralysis  of  both  lower 
extremities  followed  by  partial  paralysis  of  both  arms ;  inability  t<  > 
lift  head;  left  facial  paralysis  and  convergent  strabismus  of  left 
eye.  Patellar  reflexes  abolished;  Babiaski's  sign  present;  twelfth 
day,  motion  returned  to  arms;  fourteenth  day,  motion  returned  to 
limbs;  fifteenth  day,  paralysis  of  rectus  subsided;  eighteenth  day, 
involvement  of  hypoglossal;  twenty-fourth  day.  twitching  of  arms 
and  legs;  twenty-sixth  day,  spastic  contraction  of  hands;  thirty- 
seventh  day,  crowing  spasms  of  larynx ;  thirty-eighth  day,  tempera- 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS. 


153 


ture  108.2°  F.,  per  rectum;  respiration  rapid  and  irregular,  be- 
coming Cheyne-Stokes  in  type ;  fortieth  day,  moist  rales  over  lower 
lobes  of  lungs,  and  dullness  over  same  area.  Death  occurred  on 
fortieth  day,  at  5.30  P.M.,  the  temperature  (rectal)  one  hour  previous 
being  110°  F.  and  pulse  154.  Dr.  Fellman's  diagnosis  was  "infantile 
paralysis  of  cerebral  origin."  (Dr.  G.  H.  Fellman,  Milwaukee, 
Wis.) 


Fig.  47. — Same  as  Fig.  46. 
terior  surface. 


Pos- 


Fig.  46. — Spinal  type.  Paralysis  of 
serrati,  latissimus  dorsi,  and  erectors 
of  spine;  atrophy;  scoliosis.  Ante- 
rior surface.  (N.  Y.  Hospital  for 
Deformities  and  Joint  Diseases.) 


The  paralysis  in  this  case  was  of  the  ascending  type; 
we  are  indebted  to  a  careful  observer  for  this  first  record 
of  great  disturbance  of  the  heat  center  as  shown  by  a  rectal 
temperature  of  108°  to  110°  F.  It  probably  occurs  and  is 
overlooked  in  many  cases  of  poliomyelitis.  The  steady 
progression  of  the  paralysis,  which  in  this  case  was  much 


154  INFANTILE    PARALYSIS. 

prolonged,  is  shown  by  the  late  involvement  of  the  cortex 
(spastic  contractions  twenty-sixth  day)  and  final  involve- 
ment of  centers  of  respiration  and  heat. 

Case  of  Deseendiiif/  Type  with  Death  on  the  Fourth  Day. 
— V.  H.,  female,  3  years  and  9  months.  August  2/th,  vomited 
pear;  28,  vomited  everything  given  her,  including  water;  played 
about,  was  sleepy;  8  P.M.,  physician  called;  temperature  102°  F. ; 
knee-jerk  present,  pupils  reacted ;  Kernig  absent.  Gave  calomel  and 
ordered  baths  and  ice  to  suck;  29th,  temperature  100.3°  F- 5  vomited 
everything  given  her;  slightly  jerky;  no  other  symptoms.  3.30  P.M., 
all  attempts  to  drink  choked  her  and  liquids  came  out  through  the 
nostrils;  with  some  ejection  of  frothy  substance  from  mouth;  8 
P.M.,  throat  filled  with  saliva  and  air-bubbles,  regurgitated  one-half 
teaspoonful  of  water;  9.30  P.M.,  temperature  10x3.5°  F. ;  pulse  good; 
child  looked  well  except  for  paralysis  of  deglutition.  August  3Oth, 
2  A.M.,  child  dying;  no  convulsions;  no  other  paralysis;  died  at 
4.30  A.M.  (Armstrong  and  Cowern,  17  cases  of  poliomyelitis  at 
St.  Paul,  Minn.,  in  1909.) 

The  separation  of  the  acute  ascending  (or  descending) 
paralysis  from  the  spinal  type  is  wholly  arbitrary,  and  ac- 
cording to  Wickmann  such  cases  belong  to  the  spinal  type 
unless  there  is  a  fatal  involvement  of  the  muscles  of 
respiration. 

The  paralysis  in  these  cases  makes  steady  progress,  up- 
ward or  downward  from  the  area  first  involved,  until 
paralysis  of  respiration  closes  the  scene. 

IV.  ACUTE  BULBAR-PONTINE  TYPE  OF  POLIOMYELITIS. 

Case  of  Bulbar  Type  zvith  Moderate  Coitical  Involvement. 
— The  patient,  a  child  of  2^/2  years,  could  not  protrude  the  tongue ; 
not  only  was  the  left  side  of  the  face  paralyzed,  but  there  wa> 
oculomotor  paralysis  and  motor  paralysis  of  the  fifth  nerve,  with 
the  consequent  strabismus  and  ptosis,  and  inability  to  close  the 
jaws.  This  was  later  associated  with  a  spastic  paralysis  of  the 
right  arm  and  leg,  showing  a  spread  of  the  lesion  and  the  involve- 
ment of  the  upper  motor  neurons  to  the  limbs  of  the  opposite  side 


SPECIAL   TYPES    OF    ACUTE    POLIOMYELITIS.  155 

of  the  body.  The  child  eventually  made  a  good  recovery.  (Or. 
Colin  K.  Russel,  Montreal,  38  recent  cases;  a  study  of  poliomyelitis  i 
Case  of  Bnlbar  Type  i^itJi  Cranial-ncrrc  Inrolremcnt  Only. 
—\\'.  C,  male,  6  years ;  fever,  headache,  stiff  neck,  constipation ; 
unconscious  for  several  days;  difficult  breathing;  inability  to 
swallow;  loss  of  hearing  and  speech  for  eight  days;  eighth  day. 
right  facial  paralysis;  difficult  mastication.  Facial  and  hypoglossal 
paralysis  lasted  for  six  weeks.  Complete  recovery.  (Dr.  Kelly. 
Bulletin  \Yashington  State  Board  of  Health,  i 

In  the  bulbar-pontine  form  there  is  paralysis  of  the 
muscles  supplied  by  nerves  which  take  their  origin  in  the 
medulla  or  pons ;  the  cranial  nerves  most  often  involved  are 
the  facial,  hypoglossal,  and  ocular.  There  may  be  involve- 
ment of  the  throat  and  larynx.  Cases  of  the  bulbar-pontine 
type  may  be  associated  with  a  spastic  paralysis  due  to  cor- 
tical involvement,  as  in  the  first  case  above  given,  with  a 
lower  segment  paralysis;  with  acute  respiratory  paralysis 
and  death  due  to  invasion  of  the  vital  centers  which  are 
disposed  along  the  floor  of  the  fourth  ventricle;  or  to 
tremor  and  ataxia  due  to  interruption  of  the  conducting 
fibers  from  the  cerebellum. 

Facial  paralysis  is  the  most  frequent  manifestation  of 
this  type;  it  is  usually  unilateral,  but  may  be  bilateral.  It 
is  frequently  the  only  manifestation  of  the  acute  disease, 
and  in  sporadic  form  occurs  not  infrequently  among  adults. 
A  considerable  number  of  cases  among  adults  are  con- 
stantly in  attendance  at  the  clinic  of  the  New  York  Hos- 
pital for  Deformities  and  Joint  Diseases. 

Five  per  cent,  of  the  cases  in  the  Massachusetts  epi- 
demic of  1909  had  facial  paralysis. 

Ocular  disturbances  are  common.  There  may  be  a 
transient  nystagmus  or  diplopia.  Internal  squint,  due  to 
involvement  of  the  external  rectus,  and  divergent  squint 
with  ptosis,  from  paralysis  of  the  oculomotor,  are  often 
seen.  There  may  be  fixation  from  paralysis  of  all  the 


156  INFANTILE    PARALYSIS. 

muscles.  There  may  be  transient  blindness;  or  optic 
atrophy  with  permanent  blindness. 

Stephenson,  of  London,  has  observed  a  group  of  cases 
in  children  the  chief  characteristic  of  which  is  the  sudden 
onset  of  strabismus  at  an  age  when  ordinary  squint  is  not 
altogether  common.  The  child,  often  apparently  in  usual 
health,  is  put  to  bed,  and  on  awakening  next  morning  is 
found  to  present  squint.  Stephenson's  observations  lead 
him  to  conclude  that  the  oculomotor  symptoms  in  these 
cases  depend  on  an  acute  focal  encephalitis,  quite  analo- 
gous with  the  better-known  forms  of  that  disease.  He  has 
seen  28  such  cases,  all  the  patients  being  under  6  years  of 
age,  and  half  of  the  number  under  i  year.  Although  the 
paralysis  may  affect  any  of  the  extrinsic  muscles  of  the 
eyeball,  yet  in  three-fourths  of  the  cases  the  external  rectus 
muscle  alone  is  involved.  The  extrinsic  musculature  of 
the  eye  is  seldom  attacked.  Stephenson  says  that  the  com- 
mon form  of  encephalic  strabismus  is  very  apt  to  be  con- 
fused with  ordinary  concomitant  convergent  strabismus. 

Transient  aphasias  and  transient  deafness  are  not 
rarely  seen  in  this  type  of  poliomyelitis.  Dysphagia,  with 
salivation  and  regurgitation  of  all  liquids  through  the 
nares,  is  frequent.  Dyspnea  and  the  Cheyne-Stokes  syn- 
drome, when  there  is  no  paralysis  of  the  chest  muscles, 
point  to  alarming  involvement  of  the  pneumogastric 
centers. 

V.  ENCEPHALIC  TYPE. 

Cases  of  spastic  hemiplegia  with  resultant  contrac- 
tions, but  no  atrophy,  are  frequently  seen  in  close  associa- 
tion with  cases  of  the  flaccid  paralytic  type.  The  associa- 
tion may  occur  in  two  members  of  the  same  family,  and 
this  association  is  not  infrequently  seen  in  one  individual 
who  presents,  after  the  acute  attack,  both  spastic  and 
flaccid  lesions. 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS. 


157 


Fig.  48. — Atrophy  and  lordosis  with  Fig.  49. — Same  as  Fig.  48.     Pos- 

rotation     following     upper     segment  terior  view. 

paralysis,  with  paralysis  of  serrati, 
latissimus  dorsi,  and  erector  spinse. 
Anterior  view.  (X.  Y.  Hospital  for 
Deformities  and  Joint  Diseases.) 

Spastic  lesions  arise  from  injury  to  the  motor  cortex 
of  the  cerebrum,  or  destructive  invasion  of  its  paths  of 
conduction. 

A  spastic  paralysis,  however,  is  but  one  of  the  results 
of  an  encephalitis  produced  by  the  virus  of  poliomyelitis. 


158 


INFANTILE    PARALYSIS. 


There  may  be  associated  with  the  spastic  paralysis :  tremor, 
an  acute  ataxia,  athetosis,  and  clouded  mentality. 

The  association  of  a  flaccid  paralysis  of  the  extensors 
of  one  or  both  legs,  with  a  spastic  condition  of  the  great 


Fig.   50. — Oculomotor  type.     Strabismus.      (N.   Y.   Hospital    for 
Deformities  and  Joint  Diseases.) 

toe  or  toes,  or  of  the  fingers  of  the  hand  of  the  opposite 
side,  is  seen  so  frequently  in  the  clinic  of  the  New  York- 
Hospital  for  Deformities  as  not  to  arouse  comment. 

Three  cases,  the  first  and  third  of  which  were  seen  at 
this  clinic,  are  given :— 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS. 


159 


Hospital  for  Deformities,  Examining  Room,  May,  1911.  M.  K., 
4-year-old  girl,  of  Irish- American  parentage;  well  developed;  con- 
scious; carried  in  by  mother.  Onset  ten  days  previous,  with  fever 
and  vomiting.  Child  spastic  and  rigid  from  head  to  heels;  spas- 
ticity  increased  on  handling;  when  placed  on  feet  on  examining 
table  child  was  rigid  as  a  bottle  and  could  be  passed  back  and  forth 
between  the  hands  as  a  bottle  might  be  if  tapped  lightly  on  the  neck ; 


Fig.   51. — Oculomotor  type.     Strabismus.      (X.   Y.   Hospital   for 

Deformities  and  Joint  Diseases.) 

• 

this  action   increased   the   spasticity   until  the   child   was  standing 
rigidly  and  involuntarily  on  tiptoes. 

Armstrong  and  Cowern,  of  St.  Paul,  reported  17  cases 
of  poliomyelitis,  in  1909. 

C.  T..  aged  6  years,  female;  Sept.  3d,  malaise  and  headache; 
Sept.  4th.  feverish,  drowsy,  constipated ;  Sept.  5th,  5  P.M.,  first  seen 
by  physician,  who  considered  it  a  case  of  indigestion,  gave  calomel, 


160  IXFAXT1LE    PARALYSIS. 

and  ordered  citrate  of  potassium,  which  was  vomited.  Vomited 
several  times;  told  her  mother  her  left  hand  hurt  her  and  "wanted 
to  stay  shut."  Sept.  6th.  paralysis  of  hand;  could  not  extend 
fingers.  Child  was  up  and  appeared  well  save  for  a  "wobbly"  gait. 
Feb.  19,  1910,  child  carries  left  hand  in  right;  with  effort  she  can 
extend  fingers  and  thumb,  and  the  fingers  are  in  a  state  of  semi- 
flexion  with  distal  joint  of  thumb  semiflexed.  This  was  a  case  of 
direct  infection  from  a  cousin. 

Hospital  for  Deformities,  May,  1911. — F.  B.,  male  aged  19 
months.  \Yell-developed  boy ;  American  parents ;  walked  and  talked 
at  14  months.  Acute  onset,  April  19,  1911  (a  sister  also  contracted 
the  disease,  but  made  a  good  recovery).  High  fever;  head  sweating; 
strabismus ;  opisthotonus ;  unconscious  nine  days.  Five  weeks  later, 
paralysis  of  extensors  of  both  legs ;  spastic  right  and  left  great  toes ; 
fingers  of  both  hands  spastic,  and  hands  and  arms  constantly  em- 
ployed in  slow,  athetoid  movement  when  awake.  Constant  slow, 
vermicular  motion  of  torso;  makes  no  effort  to  sit,  stand,  or  talk. 

Head  hydrocephalic.  circumference  i8*4  inches;  fontanels  un- 
closed ;  mentality  clouded,  but  recognizes  parents  ;  marked  irritability. 

A  case  of  spastic  paralysis  in  an  adult  has  been  reported 
by  Drs.  Anderson  and  Frost : — 

Mrs.  W.,  22,  waitress,  was  taken  sick  the  latter  part  of  June. 
1910,  with  fever  and  indefinite  general  symptoms.  After  several 
days  she  became  paralyzed  in  both  lower  limbs.  She  was  admitted 
to  a  hospital  about  one  week  after  onset.  She  was  said  to  have  had. 
at  that  time,  a  flaccid  motor  paralysis  of  both  lower  extremities, 
which,  however,  became  spastic  within  a  few  days.  When  the  pa- 
tient was  seen,  the  latter  part  of  July,  1910,  both  legs  and  tint/Its 
were  quite  spastic.  No  active  motion  was  possible  except  of  the 
toes  and  slight  flexion  of  the  left  knee.  Passive  motion  was  limited 
to  partial  flexion  of  the  thighs  and  slight  flexion  of  left  knee — very 
little  of  the  right  knee.  The  patellar  reflexes  greatly  exaggerated  on 
both  sides ;  ankle-clonus  on  right  side ;  sensation  for  touch  and  pain 
was  normal.  Examination  was  otherwise  negative.  The  patient's 
general  health  was  good. 

November  25,  1910,  the  left  leg  could  be  moved,  but  rather 
awkwardly.  The  right  leg  showed  little,  if  any,  improvement. 
Patellar  reflexes  were  still  exaggerated,  more  so  on  the  right  side. 
There  was  no  ankle-clonus  and  no  atrophy. 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS.  161 

"The  spasticity  of  the  paralyzed  limbs,  exaggeration 
of  reflexes,  and  absence  of  atrophy  in  this  case  indicated  a 
lesion  in  the  upper  motor  segment,  either  in  the  motor 
cortex  of  the  brain  -or  in  the  pyramidal  tracts  of  the  cord. 
The  case  was  included  in  our  series  in  order  to  ascertain 
the  diagnosis,  since  it  represents  a  rare  clinical  type  of 
poliomyelitis,  the  diagnosis  of  which  has  always  been  un- 
certain, and  whose  occurrence  has  been  a  matter  of  some 
dispute."  (Anderson  and  Frost.) 

In  Sophian's  series  of  20  cases  seen  in  a  period  of 
three  weeks  during  the  Xew  York  epidemic  of  1911,  12 
of  the  cases  wrere  of  the  encephalic  type,  that  is,  60  per 
cent,  of  a  group  of  cases  of  poliomyelitis  presented  a  pre- 
ponderating cerebral  involvement.  This  is  a  possible  re- 
sult of  epidemic  poliomyelitis  that  is  little  known,  and  of 
extreme  importance,  and  Dr.  Sophian's  brief  table  of  the 
20  cases  is  therefore  given:— 

TWKXTY  CASES  FROM  FALL  EPIDEMIC  OF  1911. 

1 .  .Myelitic  form   3  cases. 

All  showed  paralysis  of  both  lower  extremities. 

2.  Landry's  ascending i  case. 

All  4  extremities,  intercostals,  and  face. 

3.  Abortive  form  (one  ataxic) 4  cases. 

Slight,  temporary  quadriceps,  paralysis  with  ataxia,  i  case. 
Temporary  paralysis  right  side  of  face  and  arm,  i  case. 

4.  I'olioencephalitic,  cerebral  forms   12  cases. 

Ilemiplegia  in  5  cases;  bulbar  involvement  in  3. 
Ophthalmoplegia  (complete),  2  cases,  associated  with  left 

facial  palsy  in  i  case,  and  with  palsy  of  the  left  lower 

extremity  in  the  other. 
lUilbar  involvement,  alone,  i  case. 
lUilbar  involvement,  with  paralysis  of  one  upper  extremity, 

i  case. 

(See  3  cases  of  bulbar  involvement  with  hemiplegia.) 
Isolated  paralysis,  2  cases. 
Left  facial,  right  facial  and  right  upper  extremity,  i  case. 


162  INFANTILE    PARALYSIS. 

Left  upper  extremity,  left  side  of   face,  internal  left  eye. 

i    ease. 

XOTE. — /  case  with  left  facial  palsy,  and  a  left-arm  paralysis,  the 
latter  possibly  myelitic  in  origin. 

Ages  of  cases  ranged   from  3  weeks   to  22  year-,      t  Sophian. 
Xew  York. ) 


Fig.  52.— Acute  bulbar  type.     Left  facial.      (X.  Y.  Hospital   for 
Deformities  and  Joint  Diseases.) 

Classification    of    Symptoms    of    Encephalic    Type.— 
Modified  from  Reginald  Miller. 

Polioencephalitis    superior.       Rolamlic    cortex-spastic 
hemiplegxas  (Strumpell's  paralysis). 

Frontal  area — associated  with  mental  defectives   and 
morons. 

<  )ccipital  area — blindness  with  normal  eye-grounds  and 
active  pupils. 


SPECIAL   TYPES    OF    ACUTE    POLIOMYELITIS.  163 

Symptoms  common  to  all :  Stupor,  coma,  meningitic 
cry,  bulging  fontanels. 

Polioencephalitis  inferior  (bulbar-pontine  type — see 
above).  Paralysis  facial,  oculomotor — auditory — one  side 
only.  Tremor  (pontine) :  bulbar  paralysis  (vital  center  of 
medulla ) . 


Fig.  53. — Acute  bulbar  type.     Right  facial.     (X.  Y.  Hospital  for 
Deformities  and  Joint  Diseases.^ 

Encephalitis  cerebelli  (predominant  ataxia  type). 
Ataxia  well  marked  or  extreme;  not  demonstrable  while 
patient  is  stuporous,  evident  when  patient  rallies  and  makes 
voluntary  movement;  nystagmus;  scanning  speech.  (Clin- 
ical diagnosis  confirmed  twice;  post  mortem  in  i  recent 
case  and  in  i  case  of  thirty  years'  standing.) 

Encephalitis  of  midbrain  and  connections:  Acute 
tremor;  hypertonus:  excessive  emotionalism.  Tremor,  due 


164  INFANTILE    PARALYSIS. 

to  the  alternate  action  of  groups  of  muscles  and  their  an- 
tagonists ;  a  slow,  rhythmic  movement  of  the  intention  type, 
at  the  rate  of  about  five  a  second.  It  is  of  the  intention 
type,  and  appears  only  when  an  attempt  is  made  to  use  the 
affected  limb.  Hypertonus,  not  a  true  spastic  condition, 
but  sufficient  to  make  the  movement  of  limbs  slow,  stiff, 
and  awkward. 

Thalamic  encephalitis :  Spastic  paraplegias  and  hemi- 
plegias  may  have  an  associated  athetosis  or  chorea  due  to 
lesions  in  the  optic  thalami.  (See  111,  encephalic  type, 
below.) 

All  types  of  encephalitis  enumerated  above  may 
occur :— 

I.   In  epidemic  form. 
II.  In  sporadic  form. 

III.  As  congenital  cases  from  intra-uterine  infection. 
Congenital  spastic  paraplegias.  Mental  deficiencies  of  all 
degrees. 

Polioencephalitis  of  a  pure  type,  with  no  paralysis, 
spastic  or  otherwise,  may  occur.  This  class  of  case  among 
male  adults  is  almost  uniformly  fatal,  and  is  rarely  recog- 
nized in  its  relation  to  the  epidemic  disease.  Such  a  case, 
confirmed  by  the  post-mortem  examination,  is  here  given  :— 

Anatomic  Investigation  of  19  Cases  of  ILpidcmic  .Icntc  Polio- 
myelitis.— Male,  39  years;  fever;  headache,  stiff  neck,  vomiting, 
some  rigidity  of  limbs,  couvulsive  seizures,  clouded  consciousm-^- : 
coma,  death  on  twelfth  day;  no  paralysis  nor  paresis. 

Necropsy. — Diffuse  hyperemia  of  central  nervous  system ; 
softened  encephalitic  foci  in  the  right  temporal  lobe  and  gyms 
fornicatus  of  both  sides.  Inflammation  extended  with  lessened  in- 
tensity to  basal  ganglia,  along  aqueduct  of  Sylvius,  through  medulla 
oblongata  and  was  even  demonstrable  in  upper  portions  of  cord. 
(Harbitz  and  Scheel.) 

Gregor  and  Hopper  reported  132  cases  of  poliomyelitis 
in  Cornwall  and  Devon,  Kngland,  in  1911.  One  case 
follows : — 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS.  165 

O.  N.  B.,  male;  onset  August  23th,  temperature  100°  to  101° 
F. ;  vomiting.  August  3Oth,  very  irritable.  Kernig  present  on 
both  sides ;  f undi  normal ;  paralysis  of  external  recti ;  no  other 
paralysis.  September  2cl,  semicomatose,  gradually  deepening  to 
stupor.  September  3d,  coma,  died. 

Frontal-area  Involvement,  with  Resulting  Mental  De- 
feet. — Feeble-minded  conditions  subsequent  to  and  caused 
by  acute  poliomyeloencephalitis  have  received  little  con- 
sideration as  yet  by  investigators  of  the  recent  pandemics 
of  the  disease;  the  writer  considers  it  probable  that  a 
majority  of  all  morons,  idiots,  and  imbeciles  are  victims 
of  this  acute  infection  of  the  nervous  system.  Of  the  few 
brief  references  in  the  literature  there  is  one  of  Dr.  Mark 
Grain,  of  Vermont,  to  the  effect  that  he  observed  a  child 
which  became  feeble-minded  after  an  attack  of  the  disease. 

PREDOMINANT  ACUTE  ATAXIA  TYPE. 

In  the  foregoing  classification  of  cases  of  polioenceph- 
alitis  according  to  their  cerebral  localization,  it  will  be 
seen  that  the  cases  of  acute  ataxia  are  included  in  the 
subhead  ''encephalitis  cerebelli."  \Yhile  it  is  true  that 
some  degree  of  ataxia  may  be  present  at  the  onset  of  any 
case,  there  is  a  type  of  case  in  which  ataxia  of  an  acute  and 
extreme  degree  has  been  the  predominant  feature.  These 
cases  are  not  common;  and  as  it  has  now  been  demon- 
strated that  they  have  their  origin  in  a  cerebellar  or  pon- 
tine  crossing  lesion,  there  is  no  necessity  of  giving  them  a 
further  classification  than  their  proper  alignment  in  the 
encephalic  group. 

Acute  ataxia  is  the  prominent  symptom  of  this  group, 
developing  suddenly  and  associated  with  systemic  disturb- 
ance. \Yhile  the  patient  is  in  a  comatose  state  the  ataxia 
will  be  masked,  but  becomes  apparent  as  the  patient  con- 
valesces. A  child  may  attempt  to  stand  by  placing  its  feet 
wide  apart,  and  to  walk  by  taking  short  steps,  but  will 


166 


1XKAXTILE    PARALYSIS. 


sway  and  fall.  These  cases  will  stand  and  step  more 
readily  when  placed  in  a  water  bath  hip-deep,  but  must  he 
supported  and  watched  while  in  the  water. 


Fig.  54. — Congenital  spastic  paralysis.     (N.  Y.  Hospital  for 
Deformities  and  Joint  Diseases.) 

The  ataxia  may  be  well  marked  and  lias  been  called  a 
"wild  ataxia"  by  Leonard  Parsons.  There  can  usually  be 
found  reflex  extensor  plantar  responses.  Xysta^mus, 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS. 


167 


scanning'  speech,  and  hypertonus  of  muscles  may  be  asso- 
ciated. 

This  acute  ataxia  was  first  described  bv   Levden  in 


Fig.  55. — Same  case  as  Fig.  54. 

iS<)i  ;  a  number  of  cases  have  been  reported  in  England 
(Batten  ).  The  clinical  diagnosis  has  twice  been  confirmed 
by  autopsy.  An  early  case  was  reported  from  Germany  in 


168  1XFAXTILE    PARALYSIS. 

1895 ;  a  case  of  thirty  years'  standing  was  described  by 
Clapton  (Reginal  Miller). 

E.  S.  White,  female.  Kentuckian.  12  years;  onset  July  5,  1911. 
headache,  fever,  rapid  pulse ;  movements  impaired  and  locomotion 
embarrassed ;  August  i8th,  referred  to  Ohio  Medical  College  Clinic. 


Fig.  56.— Bilateral  drop- foot.     (X.  V.  Hospital   for 
Deformities  and  Joint  Diseases.) 

Emaciated,  weak,  headache,  projectile  vomiting.  Slight  internal 
strabismus  of  left  eye;  right  side  of  face  paralyzed,  tongue  pro- 
truded to  right,  speech  inhibited;  sternocleidomastoid  of  right  side 
a  flaccid  paralysis  with  peculiar  position  of  head.  A  distinct  cere- 
brospasmodic  gait.  A  provisional  diagnosis  of  brain  tumor  or 
basilar  meningitis  was  made,  when  younger  sister  developed  symp- 
toms of  infantile  paralysis,  with  paralysis  of  both  hips  and  later  the 
father  and  another  sister  became  ill.  The  cerebrospasmodic  ataxia 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS.  169 

of  the  first  case  persists.     (Batte,  Lancet-Clinic,  Cincinnati,  Decem- 
ber 2,  1911.) 

It  is  difficult  and  perhaps  unnecessary  to  draw  a  sharp 
line  between  inco-ordination  and  ataxia.  Both  may  pre- 
cede the  acute  onset  of  poliomyelitis. 


Fig.  57. — Shortening.     (X.  Y.  Hospital  for  Deformities  and  Joint  Diseases.) 

Frost  states  that  inco-ordination  may  be  ascribed  to 
several  possible  causes:— 

1.  Lesions  of  the  cerebellum. 

2.  Lesions  in  the  conducting  tracts  leading  from  the 
cerebellum. 

3.  Lesions  of  the  posterior  cornu  of  the  cord,  affecting 
muscle  sense. 

4.  Paresis  of  certain  groups  of  muscles,  disturbing  the 


170  1XFAXTILE    PARALYSIS. 

balance  between   these   and   their   opposing    (unaffected  i 
muscles. 

5.  Peripheral  neuritis. 

To  which  might  be  added  :— 

6.  Imperfectly  developed  conduction  paths  in  the  child, 
which  are  subject  to  disorganization  from  numerous  causes. 

As  has  been  stated,  the  acute  ataxia  of  predominant 
type  arises  from  the  first  or  second  of  these  lesions,  i.e., 
of  the  cerebellum  or  its  conducting  tracts.  It  is  associated 
with  exaggerated  (especially  plantar)  reflexes,  transient 
coma,  nystagmus,  scanning  speech,  and  usually  terminates 
in  recovery. 

Three  ataxia  cases  were  seen  by  Sophian  in  three 
weeks,  in  the  summer  of  1911,  among  20  cases  studied 
during  that  period. 

VI.  MENINGITIC  TYPE. 

Case:    Mcningcal  Type;  Mild. — E.  T.,  male,  8  years;  Sept.  -'5. 
1908 ;  headache ;  pain  in  neck ;  severe  pain  in  back  ;  temperature  iuj 
F. ;  no  other  case  in  house,  but  several  in  village.     Comatose  for 
several  days;  no  paralysis;  "meningeal  type,  no  spinal  symptoms." 
(Dr.  Bowles,  Eleva,  Wis.) 

Severe  Case  of  Meningeal  Type. — One  case  gave  as  exact  a 
picture  of  meningitis  as  can  be  imagined.  The  child  was  uncon- 
scious, back  bowed,  buttocks  and  head  sustaining  weight  of  child 
if  placed  on  back,  spinal  column  as  stiff  as  a  board,  spastic  paraly-i- 
of  arms  and  legs,  rotation  of  eyeballs,  mumbling  and  groaning, 
arms  crossed  rigidly  over  chest,  and  legs  flexed  and  stiff  from  c<  ni- 
tration of  hamstring  muscles.  Temperature  104.2°  F. ;  pulse  140; 
respiration  very  fast  and  labored.  Such  a  case  required  close  work 
to  differentiate.  A  lumbar  puncture  gave  a  clear  fluid  which  escaped 
under  great  tension  at  first.  The  specimen  centrifuged  and  stained 
showed  only  mononuclear  lymphocytes.  There  were  no  intracellular 
organisms  and  no  polymorphonuclear  cells,  (llallett  and  Shidler; 
Shidler,  Pediatrics,  1910.) 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS. 


171 


It  is  the  appearance  of  this  confusing  meningeal  type 
of  poliomyelitis  early  in  the  epidemic  which  has  so  often 
led  physicians  to  consider  that  they  were  facing  an  epi- 
demic of  cerebrospinal  meningitis.  The  meningeal  symp- 
toms are  characteristic  and  may  predominate.  A  paralysis 


Fig.  58. — Scoliosis,  drop-foot,  and      Fig.  59. — Posterior  view  of  Fig.  58. 
shortening.      (N.    Y.    Hospital    for 
Deformities  and  Joint  Diseases.) 

may  follow  which  at  once  clears  the  diagnosis,  but  a  certain 
percentage  of  the  cases  recover  or  die  with  no  paralysis. 
\\ickmann,  in  his  great  monograph,  states  that  clinically 
and  by  autopsy  it  was  demonstrated  that  the  whole  course 
in  some  of  these  cases  was  that  of  a  meningitis  serosa;  he 
would  also  include  sporadic  cases  of  meningitis  serosa  as 


172  1XFAXT1LE    PARALYSIS. 

due  to  poliomyelitis.  The  two  cases  given  above  illustrate 
a  mild  and  very  severe  phase  of  this  type  of  poliomyelitis. 
They  conform  absolutely  to  the  classic  conception  of  menin- 
geal irritation :  severe  headache,  pain  in  the  neck  and  spine, 
retraction  of  the  head,  contractions  of  the  spinal  muscles. 
spasticity,  and  disturbed  vision. 

In  the  Vienna  epidemic  of  1909,  Spieler  observed  8 
meningeal  forms  in  "a  series  of  44  cases:  in  4  of  these  the 
picture  resembled  tuberculous  meningitis  so  closely  as  to 
be  diagnosed  only  late  in  the  disease.  The  cases  very  fre- 
quently have  a  comparatively  lengthy  prodromal  period. 
with  beginning  change  in  mood,  fatigue,  nightly  unre>t 
with  frequent  outcries,  occasional  vomiting  with  obstipa- 
tion, suggestive  of  a  beginning  basilar  meningitis.  Then. 
in  children,  convulsions  suddenly  occur,  marked  stiffness 
of  the  neck,  irregular  pulse,  increasing  patellar  reflex L- 
which  usually  diminish  later,  facial  pareses,  strabismus. 
general  hyperesthesia,  and  vasomotor  disturbances.  At 
this  period  the  lumbar  puncture  will  show  lymphocytosi>. 
but  no  purulent  exudate.  Tn  the  favorable  cases  the  symp- 
toms begin  to  recede,  the  temperature  falls  to  normal,  the 
irritative  phenomena  diminish,  and  there  may  develop  a 
number  of  the  palsies  characteristic  of  the  spinal  form. 

A  case  of  the  meningeal  type  occurring  in  an  adult  of 
29  years  has  been  reported  by  Dr.  Jelliffe.  (Jour.  Amer. 
Med.  Assoc.,  June  24,  1911.) 

Poliomyelitis  in  pregnancy  may  take  the  ineningiiic 
form  and  simulate  eclampsia  with  the  utmost  fidelity ;  such 
a  case  was  reported  by  \Vickmann  in  a  young  woman,  six 
months  pregnant,  taken  acutely  ill,  with  retracted  head 
and  spine  followed  by  severe  convulsions.  Forced  de- 
livery was  successfully  conducted;  the  convulsions  con- 
tinued, although  the  patient  was  entirely  conscious  until 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS.  173 

death  on  the  third  day,   when  autopsy  revealed   typical 
histologic  lesions  of  acute  poliomyelitis. 

\Yith  the  meningitic  symptoms  enumerated,  there  may 
be  paralysis;  the  patient  may  he  wholly  conscious,  or  suffer 
any  degree  of  convulsive  attack,  stupor,  delirium  or  coma. 
The  only  certain  means  of  diagnosis  is  by  lumbar  puncture 
and  examination  of  the  spinal  fluid. 

VII.  NEURAL  TYPE. 

In  the  neural  type  of  poliomyelitis  the  onset  is  similar, 
but  the  pain  is  not  confined  to  the  basilar  and  spinal  areas. 
Pain  in  the  extremities  assumes  an  agonizing  character; 
there  is  tenderness  on  pressure  along  the  nerve-trunks, 
and  violent  pains  along  the  course  of  the  nerves.  The  pain 
and  tenderness  is  much  more  severe  than  is  usually  recog- 
nized, but  the  proximal  areas  of  nerve-trunks  will  be  found 
to  be  most  affected,  due  to  the  acute  process  which  is  going 
forward  in  the  spinal  ganglia,  while  in  multiple  neuritis 
the  distal  areas  of  the  periphery  are  exquisitely  tortured. 
\Yickmann  says  of  this  polyneuritic  type  that  during  epi- 
demics cases  occur  which  would  be  considered  acute  neuri- 
tis if  they  made  their  appearance  as  isolated  cases.  Clini- 
cally and  etiologically  they  are  cases  of  acute  poliomyelitis. 

Dr.  C.  A.  Anderson  states  that  22  of  86  cases  of  polio- 
myelitis were  of  markedly  neuritic  type,  with  severe,  inter- 
mittent, sharp  pains  in  one  or  more  members  during  the 
third  day  and  after.  The  severity  of  the  pain  was  usually 
in  proportion  to  the  extent  of  the  involvement.  The  pains 
last  from  one-half  to  ten  minutes. 

In  some  of  the  cases  a  flaccid  paralysis  follows. 

Cases  of  purely  neural  type  are  seen;  the  pain  may  be 
very  persistent,  and  the  case  a  long  one  of  many  weeks. 
Such  cases  present  no  paralysis,  and  the  diagnosis  is  very 
confusing  unless  the  relationship  to  a  case  of  poliomyelitis 


174  IXFAXT1LE    PARALYSIS. 

is  evident.  This  form  may  be  seen  in  adults  or  children, 
perhaps  more  frequently  among  adult  women.  Neuritis 
is  such  a  rare  disease  in  childhood  that  when  it  occurs  in- 
fantile paralysis  must  be  suspected,  the  neuritis  of  diph- 
theria having  been  previously  ruled  out. 

The  purely  neural  type  is  comparatively  rare;  pain  <»i"  a 
multiple  neuritic  character  may  be  observed  in  combination 
with  any  of  the  foregoing  types  of  the  disease.  It  differs 
from  multiple  neuritis  in  this  particular:  the  tenderness  is 
somewhat  more  extreme  in  the  proximal  areas  of  the  nerve- 
trunks,  while  in  multiple  neuritis  the  pressure  pain  in- 
creases toward  the  periphery. 

The  pain,  of  a  severe  and  intermittent  character,  is  most 
marked  along  the  course  of  the  great  nerve-trunks.  It 
recurs  at  regular  intervals,  is  increased  by  handling  of  the 
extremities,  or  movement  of  the  patient. 

The  severity  of  the  pain  seems  to  be  in  proportion  to 
the  extent  of  the  involvement.  Paresthesias  are  frequent, 
and  there  may  be  a  marked  alteration  of  temperature  sense 
and  tactile  conduction.  The  pain  may  be  severe  and  in- 
tractable; it  may  disappear  promptly  in  cases  of  the  ar- 
rested type ;  it  may  become  chronic  and  old  cases  of  polio- 
myelitis complain  of  an  ever-present  sciatica. 

The  peripheral  pain  and  soreness  is  supposed  to  be  due 
to  central  involvement.  No  involvement  of  peripheral 
nerve-filaments  has  been  found  post  mortem  in  poliomye- 
litis. Spontaneous  pain  and  pain  on  pressure  are  pro- 
nounced; there  may  even  be  objective  sensory  disturbances 
in  rare  cases,  and  especially  of  the  sensations  of  pain  and 
temperature,  from  implication  in  the  posterior  horns  of  the 
fibers  concerned  with  these  sensations.  \\  hile  we  recog- 
nize clinically  tlic  neuritic  form,  we  have  no  pathologic 
evidence  justifying  this  recognition,  as  no  changes  in  the 
nerves  have  been  noted.  I  believe,  however,  ihat  this 


SPECIAL    TYPES    OF    ACUTE    POLIOMYELITIS.  175 

failure  of  observation  is  not  from  failure  of  neuritic 
changes,  but  from  inability  to  study  the  nerves  in  cases  in 
which  neuritic  symptoms  hare  been  pronounced.  Strauss 
reports  an  infiltration  of  the  posterior-root  fibers  and  the 
arachnoid  covering  of  the  spinal  ganglia  only.  The  asso- 
ciation of  herpes  zoster  with  poliomyelitis  would  indicate 
that  there  may  be  an  unrecognized  form  of  peripheral 
neuritic  poliomyelitis,  or  that  herpes  zoster  is  an  expres- 
sion of  poliomyelitis,  attacking  the  elderly  and  under- 
nourished. 

Poliomyelitis  Affecting  the  Superficial  and  Deep 
Muscles  of  the  Xcck  and  Extremities;  Resembling  Pol\- 
ncuritis. — The  little  girl  was  3  years  old,  delicate  from 
birth  and  subject  to  frequent  "colds  and  coughs,"  appar- 
ently due  to  enlarged  tonsils  and  adenoids.  She  had  not 
been  feeling  well  for  two  days;  as  the  parents  put  it,  "was 
terribly  weak,  had  pain  in  swallowing,  and  refused  to  take 
any  nourishment."  As  I  went  about  to  examine  her  she 
cried  bitterly  with  pain.  On  one  occasion  a  mouthful  of 
water  came  back  through  the  nose.  The  throat  was  free 
from  a  deposit,  but  deglutition  was  difficult.  Her  tempera- 
ture was  only  100°  F.  She  was  able  to  move  her  legs  from 
one  part  of  the  bed  to  another,  but  complained  of  pain  while 
doing  it.  The  same  was  true  of  the  upper  extremities, 
especially  of  the  hands.  She  could  rotate  her  head  laterally 
and  there  was  neither  retraction  nor  stiffness  of  the  neck. 
\Ye  thus  had:  symmetrical  paresis  of  the  extremities, 
intense  pain,  difficult  deglutition,  regurgitation  of  fluids 
through  the  nose  and  nasal  tone  of  voice  (which  she  always 
had  owing  to  the  adenoids) — i.e.,  a  typical  picture  of  post- 
diphtheritic  neuritis — and  yet  no  history  of  diphtheria  or 
of  any  other  grave  disease  within  six  weeks  previous  to 
this  attack.  I  ordered  3  grains  of  sodium  salicylate  and 
grain  of  strychnine  to  be  given  every  three  hours. 


176  IXFAXTILE    PARALYSIS. 

The  next  day  she  was  entirely  free  from  pain  and  ap- 
parently happy. 

X<>  longer  objecting  to  the  examination,  I  went  over 
the  case  most  carefully,  and  as  I  propped  the  child  up 
against  the  pillow  to  give  a  real  good  look  at  her  throat 
I  was  surprised  to  note  that  her  head  dropped  for- 
ward upon  the  sternum  like  a  dead  weight,  the  patient 
being  unable  to  lift  it  in  position.  On  removing  the  pillow 
and  placing  the  patient  in  slanting  position,  the  head 
dropped  also  forcibly  backward.  She  has  gradually 
greatly  improved,  though  she  still  (four  years  after  the 
attack)  shows  lack  of  strength  in  the  anteroposterior 
mobility  of  the  head.  \Yith  all  our  latest  scientific  data  on 
the  subject,  I  am  not  aware  of  any  diagnostic  means  which 
would  have  enabled  to  differentiate  this  case  from  poly- 
neuritis  at  so  early  a  stage.  ( Sheffield,  New  York. ) 

Dr.  S.  Leopold,  of  Philadelphia,  writes:  "I  wish  t<> 
call  attention  to  a  case  seen  with  Dr.  Pittfield  which  is 
rather  interesting,  because  it  was  one  of  the  neuritic  type 
<  »f  poliomyelitis  of  "\Yickmann.  This  case  is  the  only  one  on 
record,  so  far  as  I  am  aware,  in  which  the  opportunity  oc- 
curred of  studying  the  peripheral  nerves.  The  case  pre- 
sented the  ordinary  type  of  poliomyelitis  with  acute  onset, 
paralysis  of  the  lower  limbs,  which,  however,  was  un- 
symmetrical,  and  tenderness  over  the  nerve-trunks,  during 
the  entire  period  of  illness,  lasting  two  months;  the  knee- 
jerks  were  lost,  and  there  was  bladder  disturbance.  The 
case  had  been  diagnosed  as  multiple  neuritis. 

"At  necropsy  I  found  a  true  picture  of  the  reparative 
stage  of  poliomyelitis,  but  I  found  the  curious  fact  that  the 
peripheral  nerve,  which  was  examined  and  placed  in  osmic 
acid  immediately  at  necropsy,  showed  practically  no  degen- 
eration that  could  account  for  the  tenderness,  while  the 
>pinal  cord  showed  an  intense  meningitis;  most  significant 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS.  177 

•was  the  involvement  of  the  posterior  roots,  the  exudate 
being  in  the  posterior  root.  The  congestion  of  the  vessels 
was  intense;  and  I  believe  that  the  tenderness  over  the 
nerve-trunks  was  of  central  origin.  The  case  is  rather 
unique  in  the  history  of  poliomyelitis."  (Jour.  Amer.  Med. 
Assoc.,  Sept.  28,  1912.) 

Herpes  Zoster. — Herpes  zoster  is  an  acute  disease  the 
lesions  of  which  are  observed  in  the  cutaneous  distribution 
of  one  or  more  nerves.  The  eruption  of  herpes  zoster  is 
unilateral ;  the  precise  limitation  of  the  eruption  to  one-half 
of  the  body  is  of  great  diagnostic  significance  (Musser). 
Pain  is  the  most  important  subjective  symptom.  The  pain 
is  localized  in  the  nerves  in  the  distribution  of  which  the 
eruption  takes  place.  The  pain  may  precede  the  eruption 
for  several  days,  and  persist  long  after  the  eruption  sub- 
sides. The  pain  is  severely  neuralgic  in  character,  and 
causes  insomnia  and  depression. 

Dr.  Spiller,  associate  in  the  Neurological  Department 
of  University  of  Pennsylvania,  considers  it  possible  an 
herpetic  type  of  poliomyelitis  may  be  established,  stating 
that  much  the  same  lesions  are  found  in  the  intervertebral 
ganglia  as  in  the  spinal  cord.  (  Spiller,  "Diagnosis  of  Polio- 
myelitis," Pa.  Med.  Jour.,  Dec.,  1911.) 

Sixteen  cases  of  herpes  zoster  occurred  coincidently 
with  the  epidemic  of  poliomyelitis  at  Penryn,  Cornwall,  in 
the  summer  of  1911  (Gregor  and  Hopper).  The  majority 
of  these  16  cases  of  herpes  zoster  occurred  in  elderly 
\\< >men.  In  many  cases  there  was  a  severe  pain  and  general 
malaise,  and  constipation  was  a  marked  feature.  The 
eruption  appeared  on  various  parts  of  the  body.  Six  had 
lesions  on  the  neck,  shoulder-blades,  deltoid,  and  pectoral 
muscles ;  4  over  the  intercostal  muscles ;  3  over  the  recti  and 
buttocks ;  3  on  the  lower  limbs. 

12 


178  1XFAXTTLE    PARALYSIS. 

Chorea. — My  attention  was  first  drawn  to  the  possi- 
bility of  chorea  being  an  acute  infectious  disease  by  Dr.  M. 
C.  Potter,  of  Rochester,  who  observed  the  onset  of  chorea 
in  a  previously  healthy  boy  10  years  of  age,  while  at  an 
early  summer  camp.  There  was  an  acute  febrile  onset  in 
this  case.  Dr.  Potter  further  correlated  the  illness  to 
the  first  exposure  to  the  bites  of  mosquitoes  during  that 
season. 

The  most  frequent  manifestation  of  chorea  is  the  in- 
volvement of  a  single  neuron,  usually  one  supplying  a  fiber 
of  the  facial  nerve,  with  an  involuntary  twitching  of  the 
muscle  motivated  by  that  fiber.  Such  lawless  and  irregular 
twitching  of  the  muscle  may,  however,  involve  an  extrem- 
ity; one  side  of,  or  the  entire  body.  The  disease  shows  a 
tendency  to  a  spontaneous  recovery,  yet  more  often  the 
patient  is  left  with  an  ungovernable  facial  spasm  for  life. 

Chorea  is  said  to  be  transmitted  (i)  by  imitation;  i  j  i 
by  heredity  :— 

1.  The  little  girl  who  plays  with  a  comrade  who  is  a 
victim  of  this  irritative  lesion  of  some  neuron  or  group 
of  neurons,  and  who  later  develops  a  twitching  of  some 
muscle  or  group  of  muscles,  is  supposed  to  have  developed 
the  spasm  voluntarily.     The  idea  is  preposterous.     She  is 
told  to  desist  from  the  practice,  and  in  a  few  weeks  per- 
haps the  spasm  disappears.    The  mother  considers  that  her 
admonition  controlled  the  supposed  mimicry.     If  the  dis- 
ease is  not  controlled,  still  the  mother  will  state  that  it 
began  from  imitation  of  another  case  of  chorea.     It  is 
stated  in  a  medical  textbook:— 

"Thus  one  child  sees  another  child  with  chorea,  and, 
through  imitation,  performs  the  same  irregular  involuntary 
movement."  (Herrick.) 

2.  Hereditary  chorea  is  said  to  be  a   rare  affection 
which  the  patient  can  usually  trace  back  through  several 


SPECIAL   TYPES    OF   ACUTE    POLIOMYELITIS.  179 

generations.  This  is  another  instance,  like  tuberculosis, 
where  it  is  difficult  to  displace  an  infection  when  it  has 
once  taken  a  firm  grip  on  a  family. 

The  etiology  of  chorea  is  as  yet  unknown,  but  the 
author  considers  it  probable  that  this  symptom  is  caused 
by  the  same  organism  that  produces  poliomyelitis.  It  may 
be  that  its  mention  here  will  induce  observation  as  to  its 
coincidental  occurrence  in  epidemics  of  poliomyelitis,  or 
even  more  directly  in  the  families  which  have  been  attacked 
by  frank  cases  of  infantile  paralysis. 

VIII.  RAPIDLY  FATAL  INSTITUTIONAL  DISEASE. 

For  emphasis  the  eighth  and  last  place  (in  this -classifi- 
cation) is  given  to  a  lethal  group,  which  may  be  hypo- 
thetical, but  distinctly  claims  consideration. 

Several  authorities  maintain  that  poliomyelitis  is 
slightly  or  not  at  all  contagious,  stating  that  cases  seldom 
develop  in  a  hospital  ward  where  others  are  present. 
\Yhile  observing  that  such  transmission  is  infrequent  in  oc- 
currence, the  claim  that  it  docs  not  occur  can  no  longer 
be  made. 

Harbitz,  of  Norway,  has  published  a  report  of  the 
transmission  of  poliomyelitis  to  2  women  nurses  in  at- 
tendance in  the  poliomyelitis  ward  of  the  Christiana  Hos- 
pital for  Contagious  Disease  in  August,  1911,  both  cases 
with  a  fatal  termination.  Other  cases  of  transmission  oc- 
curred in  this  hospital,  and  the  facts  are  of  so  much 
importance,  and  have  such  a  direct  bearing  on  the  subject 
of  institutional  poliomyelitis,  that  the  'report  is  here  in- 
cluded : — 

As  an  argument  against  the  contagiousness  of  poliomyelitis  it 
has  been  advanced  that  nurses  who  take  care  of  these  patients 
escape  the  disease.  This  argument  does  not  hold  good ;  in  a 
separate  pavilion  of  the  hospital  for  epidemic  diseases  at  Christiana 


180  iXKAXTILE    PARALYSIS. 

wore  several  poliomyelitic  patients  during  July,  August,  and  Sep- 
tember, 1911.  Two  of  their  nurses,  aged  28  and  29,  became  ill  in 
the  latter  part  of  August  and  died  with  acute  poliomyelitis.  They 
had  served  in  this  hospital  division  for  about  one  month.  The 
virus  must  have  been  quite  widely  disseminated  in  this  hospital,  be- 
cause in  August  there  occurred  in  the  diphtheria  pavilion  4  cases  of 
acute  poliomyelitis,  among  children,  of  which  3  were  in  the  same 
ward. 

In  the  scarlet-fever  pavilion  i  case  of  acute  poliomyelitis  oc- 
curred in  a  child  who  had  previously  been  taken  care  of  by  one  of 
the  two  nurses  who  died  of  poliomyelitis;  and  finally  a  nurse  who 
served  in  one  of  the  medical  sections  of  the  same  hospital  took  the 
disease  and  died.  In  this  last  case  it  was  impossible  to  trace  the 
course  of  the  infection.  These  cases,  which  occurred  almost  simul- 
taneously, can  be  explained  only  by  the  existence  of  a  direct  infection 
and  wide  dissemination  of  the  virus  among  adults  and  children. 
("Poliomyelitis  in  Norway  in  1911,"  Harbitz,  Jour.  Amer.  Med. 
Assoc.,  Sept.  7,  1912.) 

Here  is  a  total  of  8  persons,  3  nurses  and  5  children, 
contracting  epidemic  poliomyelitis  during  a  limited  period 
of  time  while  in  residence  in  an  institution ;  an  institution, 
moreover,  for  the  specific  care  of  contagious  diseases, 
where  presumably  all  the  modern  technique  of  prophylaxis 
is  known  and  rigidly  enforced.  Harbitz,  in  the  same  re- 
port, gives  one  more  instance  of  the  institutional  occurrence 
of  acute  poliomyelitis,  which  he  considers  an  instance  of  the 
latency  of  development  of  the  virus  :— 

A  young  woman  who  had  been  in  solitary  confinement  for  three 
months  in  the  prison  contracted  a  case  of  acute  poliomyelitis;  as 
hers  was  the  only  case  inside  the  prison,  it  is  reasonable  to  conclude 
that  she  came  to  the  prison  already  infected.  (Ibid. ) 

.  /  not  dissimilar  case  came  to  my  attention  in  ll'isconsin 
in  1909.  A  young  man  was  committed  to  the  county  jail, 
which  was  also  used  as  a  lodging  house  for  the  floating 
tramp  population  run  in  for  vagrancy.  The  second  month 
of  confinement  the  young  man  became  acutely  ill  and  de- 


SPECIAL   TYPES    OF    ACUTE    POLIOMYELITIS.  181 

veloped  a  paralysis  of  the  right  arm.  The  young  man's 
sweetheart  informed  me  that  there  were  vermin  in  his  cell. 
/  am  inclined  to  tlie  opinion  that  cadi  of  these  cases  re- 
sulted from  transmission  from  cases  of  the  arrested  and 
unrecognized  type,  and  may  well  have  been  occasioned  by 
the  agency  of  bedbugs.  \Ye  do  not  yet  know  the  means  of 
transmission  of  this  disease.  If  such  transmission  should 
prove  to  be  by  inoculation,  we  will  say  that,  through  the 
agency  of  cimex,  in  a  well-ordered  hospital  it  would  never 
occur. 

We  are  also  ignorant  of  the  degree  of  virulence  which 
poliomyelitis  may  attain  in  the  human  host;  in  monkeys  it 
has  attained  a  mortality  of  100  per  cent.  (Flexner, 
"Poliomyelitis/'  Jour.  Amer.  Med.  Assoc.,  Sept.  24,  1910.) 

Grant  that  a  virus  (whose  usual  strength  shows  a  mor- 
tality rate  of  15  per  cent,  and  a  disability  rate  of  60  per 
cent. )  becomes  suddenly  and  greatly  enhanced  in  virulence 
In  I'itro;  grant  that  the  usual  unknown  inhibition  of  trans- 
mission of  this  virus  is  removed  (or  the  agent  of  trans- 
mission is  present),  would  we  not  look  for  a  sudden  ac- 
celeration of  those  destructive  powers  which  have  already 
earned  from  the  public  the  name  of  the  Children's  Plague  ? 

Such  an  acute  epidemic  asphyxia  has  been  manifested 
in  the  past  in  England,  with  grave  and  alarming  results 
which  occasioned  the  publication  of  an  official  Blue  Book. 
( R.  Miller,  "Acute  Polioencephalitis,"  The  Practitioner, 
London,  April,  1910.)  The  cases  tended  to  occur  in  small 
epidemics,  in  which  after  a  few  hours'  illness  death  oc- 
curred suddenly  with  the  signs  of  an  acute  asphyxia.  The 
cases  were  supposed  to  be  occasioned  by  a  polioencephalo- 
myelitis  in  which  the  vital  centers  in  the  medulla  were  the 
first  to  be  attacked. 

\Ye  still  have  in  mind  the  sudden  and  'unexplained 
deaths-of  8  babies  in  an  institution.  A  child  with  chicken- 


182  IXFAXTILE    PARALYSIS. 

pox  was  brought  into  this  institution.  The  rash  of  polio- 
myelitis is  frequently  mistaken  for  that  of  measles  and 
chicken-pox.  The  sister  of  this  child  and  ~  other  inmates 
suddenly  died,  with  stiff  neck,  convulsions,  and  asphyxia. 
A  young'  woman  was  indicted  for  their  murder,  but  the 
charge  was  not  sustained.  Cervical  rigidity,  convulsions, 
and  paralysis  of  respiration,  as  we  have  seen,  are  the  car- 
dinal symptoms  of  the  acute  fatal  bulbar  type  of  epidemic 
poliomyelitis.  But  the  acute  fatal  bulbar  type  occur  ring- 
here  and  there  as  isolated  cases  during  an  epidemic  usually 
takes  from  three  to  seven  days  for  its  development. 

It  seems  evident  that  for  the  kindling  of  this  fire  we 
must  have  not  only  the  fuel  and  the  match,  but  the  fuel 
must  have  been  rendered  especially  inflammable,  to  make 
ignition  so  nearly  approach  an  explosion.  To  leave  the 
figure  of  speech,  children  and  adults  in  institutions  live 
.a  highly  artificial  life ;  the  child  is  susceptible  to  such  crowd- 
ing in  inverse  proportion  to  its  age ;  the  adult  seeks  the 
shelter  of  a  lodging  house  with  his  resistance  to  disease 
impaired  by  undernourishment,  exposure,  and  fatigue.  It 
is  under  similar  conditions  that  any  transmissible  disease 
may  become  suddenly  malignant  in  its  manifestations. 

Poliomyelitis  is  proved  to  be  a  transmissible  disease. 
It  .has  been  transmitted  artificially  from  man  to  monkey 
through  many  series  of  such  transmissions  by  inoculation. 
The  virus  of  poliomyelitis,  transmitted  from  man  to  the 
monkey  made  susceptible  by  a  highly  artificial  mode  of  life, 
altered  rapidly  in  potency,  until  the  mortality  rate  in  mon- 
keys reached  100  per  cent.  (Flexner).  The  virus  of  polio- 
myelitis transmitted  from  man  to  man  through  a  series  of 
human  hosts  with  lessened  resistance  and  increased  sus- 
ceptibility, would  tend  to  produce,  under  given  circum- 
stances, the  form  of  poliomyelitis  classified  as  type  8,  the 
rapidly  fatal  institutional  type  under  discussion. 


SPECIAL   TYPES    OF    ACUTE    POLIOMYELITIS.  183 

The  symptoms  of  the  fulminating  and  rapidly  fatal  cases 
which  occur  in  every  epidemic  of  poliomyelitis  may  also  be 
studied  in  relation  to  the  foregoing :  collapse ;  cold  extremi- 
lic-s  ;  vomit  ing  of  partly  digested  blood;  suffocation ;  cardiac 
paralysis.  , 

TWO  ATTACKS  OF  ACUTE  POLIOMYELITIS  IN  SAME   CASE. 

.•Icittc  .Interior  Poliomyelitis. — On  a  warm  day  in 
August,  1891,  when  25  months  old,  after  an  indiscretion 
in  diet,  and  without  antecedent  traumatism,  Eshner's  pa- 
tient was  seized  with  fever  lasting  three  days,  and  asso- 
ciated with  pain  in  the  right  leg  and  the  back.  There  had 
been  no  vomiting  and  no  diarrhea.  On  the  fifth  day  the 
right  lower  extremity  was  found  to  be  paralyzed,  without 
apparent  alteration  in  sensibility.  The  paralysis  increased 
in  severity  for  a  week,  and  then  it  began  gradually  to 
diminish.  The  upper  extremities,  the  left  lower  extremity, 
and  the  face  were  unaffected.  The  general  nutrition  was 
preserved,  but  the  right  lower  extremity  was  moderately 
wasted.  Intelligence  was  good  and  sensibility  was  un- 
affected. The  gait  was  wobbling,  the  feet  being  held  rather 
far  apart  in  walking.  There  were  no  contractures  and  no 
deformity.  The  knee-jerk  was  normal  on  the  left,  en- 
feebled on  the  right.  The  circumference  of  the  right  leg 
was  /)4  inches,  that  of  the  left  "/J/2  inches.  The  muscles 
of  the  right  leg  responded  less  well  to  faradic  stimulation 
than  did  the  muscles  of  the  left  leg,  but  there  was  no  de- 
generative reaction.  The  patient  occasionally  had  noc- 
turnal enuresis,  but  there  wras  no  evidence  of  rachitis. 
Under  treatment  with  massage  and  electricity  for  eight 
months  practical  recovery  took  place.  Eleven  years  after 
this  illness,  in  March,  1903,  a  day  after  a  fall,  resulting 
in  injury  to  the  left  shoulder  and  the  left  elbow,  the  pa- 
tient developed  weakness  in  both  hands,  more  marked  in 


184  IXFAXTILE    PARALYSIS. 

the  left.  She  had  not  been  feeling  well  at  this  time  and 
was  "nervous,"  although  she  was  attending  school  and  had 
no  fever  or  nausea  or  v<  uniting.  AYhile  the  symptoms  mani- 
fested were  those  of  acute  anterior  poliomyelitis,  Eshner 
points  out  that  someone  might  attribute  them  to  peripheral - 
nerve  injury  in  consequence  of  the  fall.  The  development 
<>f  the  symptoms  a  day  following  and  not  immediately  after 
the  accident;  the  involvement  of  both  hands  primarily,  even 
though  in  slight  degree  and  but  transitory  in  character,  on 
the  uninjured  side;  the  absence  of  sensory  alterations,  cer- 
tainly entitle  the  possibility  of  a  spinal  rather  than  a 
peripheral  lesion — a  poliomyelitis  rather  than  neuritis — to 
serious  consideration.  (Jour.  Amer.  Med.  Assoc.,  Oct. 
8,  1910.) 

RECRUDESCENCE    OF    POLIOMYELITIS. 

Eckert,  in  the  following  quotation,  gives  a  case  of  re- 
crudescence :— 

H.  Sch.  was  taken  sick  September,  1903.  with  poliomyelitis,  and 
was  paralyzed  in  the  left  leg.  Tenotomy  was  done  and  splints 
applied.  At  the  beginning  of  April,  1909,  occurred  a  second  infec- 
tion, and  paralysis  of  the  right  leg. 

"A  positive  case  of  this  nature  has  come  under  my 
observation.  In  a  family  living  in  a  typically  rural  part 
of  Massachusetts  sixteen  years  ago  a  girl,  then  3  years 
of  age,  had  an  attack  of  poliomyelitis  and  recovered  with 
a  residual  paralysis  of  the  deltoid  of  the  left  arm.  The 
family  numbered,  in  1910,  5  children — 4  girls  and  i  1><>\. 
In  1910  a  girl  12  years  of  age  became  violently  sick  and 
died  in  a  few  days.  The  attack  was  thought  to  have  been 
ptomaine  poisoning,  though  characterized  by  many  nervous 
symptoms.'  Early  in  August,  191 1,  the  family  went  for  a 
vacation  to  Maine.  After  three  weeks'  stay  in  Maine  a 
6-year-old  girl  was  taken  sick  on  August  24th  and  died 


SPECIAL   TYPES   OF  ACUTE   POLIOMYELITIS.  135 

with  respiratory  paralysis  in  four  days.  No  diagnosis  was 
made  by  the  attending  physician. 

"On  August  28th,  the  boy,  3  years  and  10  months  old, 
was  taken  sick  at  \Yarren,  Me.,  in  a  similar  manner. 
There  was,  however,  a  slight  paralysis  of  left  face.  The 
family  then  returned  to  Massachusetts,  where  the  funeral 
of  the  girl  was  held. 

"On  August  3ist,  the  oldest  girl,  19  years  old  (wlm 
when  she  was  3  years  of  age  had  poliomyelitis),  was  taken 
sick  and  within  a  week  developed  a  distinct  Landry's  paral- 
ysis, involving  all  four  extremities,  neck,  back,  abdomen, 
and  respiration. 

"On  September  2d,  a  younger  sister,  aged  16  years 
and  9  months,  was  taken  similarly  sick.  She  developed 
rapidly  the  Landry  type  of  poliomyelitis  and  died  in  a  few 
days. 

"This  group  of  cases  is  doubly  interesting  from  the  fact 
that  4  cases  occurred  in  the  same  family,  and,  further,  that 
one  of  them,  the  1 9-year-old  girl,  had  had  a  previous  at- 
tack of  the  same  infection  sixteen  years  before."  (Shep- 
pard,  "Poliomyelitis  in  Springfield,  Mass.,"  1910.) 


CHAPTER   VTI. 

Diagnosis  of  Poliomyelitis  in  the  Preparalytic 

Stage. 

In  any  disease  which  is  sufficiently  serious  to  cause  death  or 
permanent  disability  within  two  to  five  days  after  its  inception,  it  is 
apparent  that  treatment,  to  prevent  such  consequences,  must  be 
promptly  instituted.  Therefore  in  every  disease  of  that  character 
it  is  absolutely  necessary  that  an  early  and  correct  diagnosis  should 
be  made.  Poliomyelitis  is  such  a  disease.  (Mclntyre,  Minnesota.) 

HALF  a  decade  in  America  has  added  one  to  the  brief 
list  of  diseases  which  the  diagnostician  must  carry  ever 
foremost  in  mind  when  called  to  attend  a  case  of  acute 
illness  in  child  or  adult.  Poliomyelitis,  because  of  its 
rapidly  destructive  or  fatal  lesions  and  its  pandemic  in- 
vasion of  the  country,  supersedes  typhoid,  scarlet  fever, 
diphtheria,  or  pneumonia,  as  well  as  all  tortoise-footed 
diseases,  in  bedside  cogitations.  The  period  of  time  elaps- 
ing between  the  onset  of  the  disease  and  the  oncoming  of 
paralysis  is  brief  indeed.  Deferring  diagnosis  until  con- 
firmation by  oncoming  paralysis  confiscates  the  hours 
during  which  treatment  modifies  the  course  of  the  disease. 
And  paralysis  may  become  apparent  only  as  a  terminal 
asphyxia. 

The  symptoms  and  signs  which  warrant  a  diagnosis 
-of  poliomyelitis  in  the  preparalytic  stage  are:— 

I.  Aura  of  onset. 
II.  Hyperesthesia  a  cardinal  symptom. 

III.  Cervical  tension  a  cardinal  symptom. 

IV.  Hyperpyrexia,  which  declines  by  crisis. 

V.  Increased  respiration  rate  with  no  lung  findings. 
VI.  Pulse  range  120  to  200. 
(186) 


POLIOMYELITIS    IX    THE    PREPARALYTIC    STAGE.         187 

VII.  Basilar  headache,   considered   intolerable. 

VIII.  Backache,  considered  intolerable. 

IX.  Knee-jerk    exaggerated,    diminished,    lost,    and 

unequal  in  2  cases. 

X.  Vomiting. 

XL  Constipation. 

XII.  Retention  of  urine. 

XIII.  Rash,  measly  or  purpuric. 

XIV.  Epistaxis. 

XV.   Bulging  fontanels. 
XVI.   Unbroken  orientation  and  unimpaired  judgment. 

AURA  OF  ONSET. 

The  onset  of  the  disease  is  the  same  in  cases  which 
later  show  cerebral  or  spinal  localization,  or  pass  into' the 
arrested  form  of  the  disease;  but  such  is  the  toxic  affinity 
of  the  virus  for  the  integers  of  the  nervous  system,  that  a 
neuropathic  aura  precedes  the  acute  onset  in  a  majority 
of  cases.  Dizziness,  ataxia,  and  inco-ordination  in  the 
adult;  tremor,  quivering  eyelids,  stumbling,  and  unaccus- 
tomed falls  in  the  child  are  the  frequently  observed  warn- 
ings of  the  oncoming  of  the  onset  of  this  disease. 

HYPERESTHESIA. 

Hyperesthesia  is  the  characteristic  diagnostic  symptom 
of  onset  of  poliomyelitis.  This  hyperesthesia  is  always 
present  at  some  level  of  trie  spine ;  usually  cervical,  it  may 
extend  down  to  the  sacrum ;  it  is  also  found  present  in  that 
area  of  the  torso  or  extremities  which  will  later  be  para- 
lyzed. This  hyperesthesia  is  almost  intolerable ;  the  physi- 
cian will  be  amazed  at  the  agonized  resistance  to  handling 
of  some  child  who  has  hitherto  regarded  him  as  a  friend ; 
the  pain  is  so  exquisite  as  to  wring  from  a  grown  man  the 
wish  that  his  arm  might  be  cut  off;  the  hyperesthesia  of 


1,S8  INFANTILE    PARALYSIS. 

the  muscles  of  the  shoulder-girdle  has  prompted  a  diag- 
nosis of  dislocation  of  the  shoulder;  a  child  will  scream 
with  the  pain  in  the  preparalytic  leg  when  placed  on  the 
bedpan ;  Miiller  reports  a  case  in  which  a  diagnosis  of  ap- 
pendicitis was  occasioned  by  the  hyperesthesia  of  the  right 
abdominal  parietes  subsequently  paretic,  and  considers 
that  this  symptom  alone  is  sufficient  for  diagnosis  in  the 
illness  of  a  hitherto  healthy  child.  This  hyperesthesia  ap- 
pears to  be  a  severe  myalgia,  and  is  also  frequently  mistaken 


;v-. 


Fig.  60. — Profound  stupor,  paralysis  of  left  arm,  retraction  of  neck. 
(After  Peabody,  Draper,  and  Dochez.} 

for  rheumatism.  The  cause  of  the  hyperesthesia  is  the  in- 
volvement of  both  anterior  and  posterior  spinal  ganglia, 
where  fibers  of  pain,  temperature,  and  tactile  sense  affiliate 
with  fibers  of  the  sympathetic,  and  then  fuse  with  motor 
conduction  fibers. 

CERVICAL  TENSION. 

A  stiff  neck  is  the  constant  accompaniment  of  onset; 
it  is  usually  associated  with  basilar  headache  and  back- 
ache; the  extensor  cervical  muscles  are  spastic  and  the 
rigidity  is  demonstrated  by  flexing  the  head  on  the  chest ; 
in  one  of  Shidler's  cases,  a  lo-year-old  girl,  the  initial 


POLIOMYELITIS    IX    THE    PREPARALYTIC    STAGE. 


189 


symptom  was  an  inability  to  see  down  a  posthole  when  she 
stood  close  to  it  because  of  the  stiffness  of  the  neck  muscles. 
If  the  child  is  told  to  place  the  chin  on  his  chest  he  will 
do  so  by  dropping  the  jaw.  The  rigidity  is  anteroposterior ; 
lateral  motion  of  the  head  is  possible  in  those  cases  in 


Fig.  61.  Fig.  62. 

Intercostal  paralysis,  protrusion  of  abdomen,  and  retraction  of  thorax. 
(After  Peabody,  Draper,  and  Dochez.) 

which  there  is  no  involvement  of  the  sternomastoid.  If 
there  is  a  considerable  spasticity  the  head  will  be  retracted, 
the  chin  well  up  if  the  child  is  going  about,  or  noticeably 
extended  on  the  pillow ;  stooping  forward  is  so  painful  the 
child  may  refuse  to  drink,  according  to  Anderson,  or  the 


190  IXFAXTILE    PARALYSIS. 

nursling  to  nurse.  Armstrong  reports  a  case  of  a  5-year- 
old  boy  who  for  one  week  laid  on  his  face  "because  it  hurt 
his  neck  to  lie  on  his  back."  The  entire  spine  may  be 
spastic,  with  the  torso  rigid  as  a  board.  Opisthotonos  is 
not  uncommon.  Convulsions  are  fairly  frequent  in  young 
children,  and  in  at  least  I  case,  a  young  male  of  20  years, 
convulsions  were  severe  and  continued  for  twentv  hours. 


resulting  in  death. 


HYPERPYREXIA. 


A  high  fever,  which  may  be  preceded  by  a  chill  and 
accompanied  by  severe  sweating,  is  characteristic  of  the 
onset;  Draper  and  Peabody  consider  it  the  most  charac- 
teristic of  all  symptoms.  The  rise  in  temperature  is  in- 
variable, but  frequently  overlooked.  The  fever  declir.es 
by  crisis,  with  the  amelioration  of  other  acute  symptoms 
preceding  the  onset  of  the  paresis  or  paralysis.  With  in- 
volvement of  the  heat  centers  in  the  ascending  type  the 
fever  may  rise  to  107-110°  F.,  rectal  record;  these  cases 
suggest  heat  stroke  and  have  been  mistaken  for  heat  pros- 
tration. 

INCREASED  RESPIRATION  RATE. 

The  respiration  rate  is  about  doubled  and  ma}'  be 
trebled  at  onset;  there  are  no  lung  findings,  and  the  tre- 
mendous increase  in  the  number  of  inspirations  is  very 
puzzling  until  it  is  recalled  that  the  centers  for  respiration 
and  the  phrenic  nerve  are  comprehended  in  the  cervical 
plexus;  the  constant  cervical  tension  of  onset  would  indi- 
cate that  the  cervical  spinal  nerves  are  first  involved  in  all 
cases.  This  hurried  breathing  is  early;  later,  with  the 
onset  of  paralysis  in  thoracic  and  diaphragmatic  fibers,  the 
breathing  becomes  shallow  and  of  the  reversed  abdominal 
type,  in  which  the  upper  abdomen  is  sucked  in  during 
inspiration. 


POLIOMYELITIS    IX    THE    PREPARALYTIC    STAGE. 


191 


INCREASED  PULSE  RATE. 

There  is  a  marked  increase  in  the  pulse  during  the 
early  irritative  stage.  In  children  the  pulse  may  range 
from  1 20  to  200;  in  adults,  to  120  or  higher.  This  fact  is 
often  not  mentioned  by  other  authorities,  and  many  of  them 
omit  to  mention  cardiac  action  altogether;  it  may  be  that 
this  is  due  to  the  frequent  omission  by  the  examiner,  owing 
to  some  difficulty  in  obtaining  a  child's  pulse  rate,  of  a 
pulse  record  in  these  cases.  In  Dakin's  careful  record  <>f 
the  Mason  City,  Iowa,  cases  of  poliomyelitis  the  pulse  of 
onset  is  given  in  31  of  the  36  cases  seen:— 


Age  i  year.  i 
Age  2  years.  2 
Age  3  years.  8 
Age  4  years.  2 
Age  5  years.  2 
Age  6  years.  3 
Age  7  years.  3 
Age  8  years. 
Age  12  years,  i 
Age  16  years. 
Age  26  years. 
Age  30  years. 
Age  42  years. 
Age  44  years. 
Age  48  years. 

(Rearranged 
Nov.,  1910.) 


case.  Pulse  180. 

cases.  Pulse  130-150. 

cases.  Pulse  112-120-120-120-130-130-130-140. 

cases.  Pulse  175-180. 

cases.  Pulse  120-150. 

cases.  Pulse  140-150-190. 

cases.  Pulse   120-130-170. 

cases.  Pulse  120-150. 

case.  Pulse  120. 

case.  Pulse  120. 

case.  Pulse  100. 

cases.  Pulse     80-100. 

case.  Pulse  100. 

case.  .Pulse  100. 

case.  Pulse     90. 

from  Dakin,   "Poliomyelitis,"   Iowa  Med.  Jour., 


From  series  of  Dr.  E.  S.  Hayes,  Eau  Claire,  Wis. : — 

Sept.  12,  1908.  Mary  M.,  aged  4.  Temp.,  102°  F. ;  pulse,  140; 
paralysis.  July  23,  1908.  Baby  W.,  aged  2.  Temp.,  103°  F. ;  pulse, 
130;  paralysis.  Sept.  19,  1908.  Emil  K.,  aged  8.  Temp.,  101°  F. ; 
pulse,  130;  paresis.  (Personal  communication  to  Dr.  Manning.) 


192  1XFAXTILH    PARALYSIS. 

REFLEXES  DURING  ACUTE  STAGE. 

The  first  effect  of  the  irritative  stage  is  to  augment  the 
knee-reflex ;  it  may  be  exaggerated  in  both  knees ;  usually 
an  exaggerated  reflex  is  obtained  in  the  more  hyperesthetic 
leg,  with  no  change  in  the  reflex  of  its  fellow ;  later  there 
will  be  a  diminution  of  the  reflex  or  it  may  be  lost  in  the 
leg  first  affected,  while  at  the  same  time  the  reflex  of  the 
second  leg  will  now  show  augmentation.  Brudzinski  has 
demonstrated  two  valuable  reflexes  which  are  found  in 
children  with  acute  disease  of  cord  and  brain:  (i)  The 
contralateral  reflex  of  the  legs  consists  in  a  concomitant 
reflex  of  the  leg  on  one  side  when  passive  flexion  of  the 
leg  on  the  other  side  is  made.  This  sign  has  been  found 
useful  in  the  diagnosis  of  meningitis.  (2)  The  Brudzinski 
neck  sign  is  obtained  when  passive  flexion  of  the  neck  for- 
ward produces  flexion  of  the  legs  at  the  hips  and  knees, 
and  also  flexion  of  legs  on  pelvis.  This  reflex,  which  indi- 
cates the  presence  of  meningitis,  would  need  to  be  attempted 
with  much  gentleness  in  poliomyelitis  or  otherwise  would 
occasion  much  suffering. 

VOMITING. 

Vomiting  is  a  constant  accompaniment  of  onset ;  it  is  a 
part  of  the  paresis  of  digestion  responsible  for  the  ac- 
companying condition  of  constipation.  The  case  may  vomit 
once,  or  repeatedly.  When  projectile  vomiting  is  a  feature 
of  onset  the  case  is  usually  of  the  cerebral  type. 

CONSTIPATION. 

Constipation  is  a  feature  of  onset  of  poliomyelitis  in 
this  country ;  in  Germany  an  onset  with  diarrhea  has  been 
noted  so  frequently  as  to  be  recognized  as  characteristic. 
The  constipation  met  with  here  is  really  an  obstipation,  and 


POLIOMYELITIS    IX    THE    PREPARALYTIC    STAGE.        193 

is  usually  associated  with  difficulty  in  urination  or  reten- 
tion of  the  urine,  an  excellent  indication  that  both  condi- 
tions are  due  to  partial  paresis. 

RETENTION   OF   URINE. 

Delayed  urination  is  the  rule  and  retention  of  urine 
frequent  in  the  initial  stage.  Prompt  efforts  to  secure 
elimination  may  allay  this  condition,  but  dysuria,  reten- 
tion with  overflow,  involuntary  urination  and  anuria  have 
all  been  observed  to  occur.  A  distended  bladder  was  diag- 
nosed as  a  case  of  intussusception  and  operated,  a  subse- 
quent paralysis  clearing  diagnosis. 

SWEATING,  EPISTAXIS,  AND  CUTANEOUS  RASH, 
OR  PURPURA. 

Sweating  of  a  severe  character  has  been  reported  as 
characteristic  by  some  observers  and  ignored  by  others. 
It  is  possible  that  sweating  is  a  symptom  which,  like  the 
marked  increase  in  the  pulse  rate,  occurs  so  early  that  it  is 
missed  by  the  attendant.  Miiller  considers  the  profuse 
sweating  may  be  due  to  the  involvement  of  spinal  sweat 
centers.  I  am  now  of  the  opinion  that  the  profuse  sweat- 
ing, as  well  as  the  occasional  epistaxis,  and  the  more  than 
occasional  rash,  are  varying  manifestations  of  the  patho- 
genic permeability  of  the  blood-vessel  walls ;  these  systemic 
manifestations  of  mechanical  permeability,  varying  in  de- 
gree from  leakage  to  hemorrhage,  correspond  to  the 
process  which  is  known  to  be  taking  place  in  the  walls  of 
the  spinal  blood-vessels. 

EXAMINATION    OF    SPINAL    FLUID. 

A  quantitative  increase  in  the  spinal  fluid  is  shown  by 
symptoms  of  pressure,  bulging  of  the  fontanels,  Macewen's 
tympanitic  note,  and  accelerated  flow  on  lumbar  puncture. 


194 


1M. \\TILE    PARALYSIS. 


The  spinal  fluid  is  clear,  becoming  slightly  opalescent  at 
the  paralytic  stage,  is  sterile,  and  is  increased  in  quantity 
and  globulin  content. 

CEREBROSP1NAL  FLUID.    SOPHIAN'S  TABLE. 


Normal 

Meningism 

Poliomyelitis 
Polioencephalitis 

Cerebrospina'. 
Meningitis 

Streptococcus 
Pneumococcus 
Influenza,  etc. 
Meningitis 

Tuberculous 
Meningitis 

Color 

Clear 

Clear 

Clear,  occasionally 
bloody,  from  fresh 
or  old  hemorrhage 

Cloudy,  pus 
sediment 

Cloudy,  pus 
sediment 

Clear,   white 
flakes,  ribnn- 
network 

Pressure 

Low,  es- 
capes 
slowly 
drop  by 
drop 

to 
to 

to 

to 

Quantity 

Little,  few 
c.c. 

(Up  to  50 
c.c.     or 
more) 

(Up  to  50  c.c.  or 
more) 

(Up  to  100  c.c. 
or  more) 

(Up  to  100  c.c. 
or  more) 

(Up  to  100  c.c. 
or  more) 

Cytology 

Few  cells, 
leucocytes 
and  endo- 

thelial 

Few    cellu- 
lar ele- 
ments 

Cells  increased  in 
number 
Lymphocytes  90f< 
or  more 

Cells  numer- 
ous  (polynu- 
clear  up  to 
lOO'O 

Cells  numer- 
ous (poly  nu- 
clear up  to 
100-V) 

Cells  numer- 
ous i  lympho- 
cytes up  to 
90<0 

Bacteriol- 
ogy 

Sterile 

Sterile 

Sterile 

Meningococ- 
cus 

Infecting  or- 
ganism 

Tubercle  bacil- 
lus 

Albumin 
i  nitric 
acid  test) 

Faint  trace 

Trace 

Trace  to 

+  +  + 

+ 

Globulin  . 
test 

Negative 

Negative 

Positive  in   early 
stages 

- 

OUTLINE  FOR  SERUM  EXAMINATION.     (DUBOIS.) 
Number  of  cubic  centimeters  of  spinal  fluid. 


Clear.  Cloudy. 

Cytology. 

Bacteriology. 

Globulin. 

Albumin. 

Clinical  diagnosis. 

Animal  inoculation. 


Fibrin. 

Spread. 
(Butyric  acid  test.) 

(  Xitric  acid  test.) 


Culture 


HISTORY  OF  EXPOSURE. 

The  prevalence  of  the  disease  in  the  community  should 
always  be  considered;  a  history  of  exposure  is  strong  pre- 
sumptive evidence  of  the  presence  of  the  disease;  no  polio- 


POLIOMYELITIS    IN    THE    PREPAKALYTIC    STAGE.         195 

myelitis  in  community  does  not  negative  the  disease;  old 
cases  in  the  house  are  to  be  considered  in  the  light  of  pos- 
sible carriers. 

CEREBRAL  TYPE. 

Many  unrecognized  cases  of  the  cerebral  type  occur, 
especially  among  adult  males.  In  a  group  of  20  cases  seen 
by  Sophian  in  three  weeks'  time  during  the  fall  of  1911, 
there  were  12  cases  of  the  cerebral  type,  an  astonishing 
percentage,  which  illustrates  anew  the  fatuity  of  consider- 
ing the  spinal  myelitic  type  to  be  typical  of  this  disease. 

The  usual  picture  of  the  cerebral  case  is  a  spastic  henii- 
plegia  with  oculomotor  or  facial  involvement.  Facial 
paralysis  or  an  internal  strabismus  may  be  the  only  mani- 
festation. 

The  spastic  hemiplegic  form  in  the  adult  is  clearly  dif- 
ferentiated from  cerebral  hemorrhage  by  the  aura  of  onset, 
chill,  high  fever,  hyperesthesia,  and,  most  important  of  all, 
the  unbroken  orientation  for  time  and  place,  with  no  loss 
of  consciousness. 


CHAPTER    VIII. 
Differential  Diagnosis. 

If  we  think  of  the  disease  as  a  poliomyeloencephalitis  with 
meningeal  complications  and  appreciate  the  fact  that  the  disease  may 
affect  any  or  all  parts  of  the  gray  matter  of  the  central  nervous 
-y-tem,  and  in  all  possihle  combinations,  wo  shall  understand  better 
the  innumerable  manifestations  of  the  disease  and  be  less  likely  t<> 
overlook  it  or  mistake  it  for  some  other  condition.  \Ye  must  never 
forget  how  variable  the  symptoms  may  be.  If  we  are  awake  to  all 
the  possibilities,  we  are  not  likely  to  overlook  it.  (  Morse.) 

Meningitis. — Epidemic  cerebrospinal,  tuberculous,  sup- 
purative.  Meningism  is  one  of  the  diagnostic  signs  of  the 
onset  of  infantile  paralysis.  It  may  vary  in  degree  from 
a  slight  nuchal  tenderness  and  rigidity  to  the  most  extreme 
tvpe  of  meningeal  irritation,  the  meningeal  form  of  the 
disease.  The  diagnosis  is  usually  made  clear  by  the  ap- 
pearance of  paralysis.  Cases  appear  coincidently  with  the 
epidemic,  with  meningitic  symptoms  and  without  paralysis. 
\Yickmann  found,  clinically  and  by  autopsy,  that  such  ca<e- 
ran  the  "whole  course  as  a  meningitis  serosa." 

It  is  of  great  importance  to  make  an  early  diagn<>-i-. 
When  the  case  simulates  an  acute  meningitis,  or  a  tuber- 
culous meningitis,  lumbar  puncture,  with  an  examination 
of  the  spinal  fluid,  is  the  ready  means  of  positive  diagno-i-. 

In  a  case  of  infantile  paralysis  puncture  will  be  followed 
by  a  rapid  drop  flow,  or  even  spurting  of  the  spinal  fluid. 
Ten  c.c.  is  sufficient  for  purposes  of  examination.  I  he- 
fluid  will  be  found  clear,  or  exhibiting  a  slight  shimmering 
or  opalescence  in  the  preparalytic  stage.  On  examination 
it  will  be  found  to  be  sterile.  Lymphocytes,  small  and  large. 
make  up  90  per  cent,  of  the  white  cells,  with  a  very  few 
(1%) 


DIFFERENTIAL    DIAGNOSIS. 


polynuclear  leucocytes.  The  supernatant  fluid,  after  cen- 
trifuging,  will  give  a  marked  protein  reaction  with  the 
Xoguchi  butyric  acid  test. 


Fig.  63. — Familial  type.  Patient  one  of  three  brothers  equally 
afflicted.  This  case  steadily  improving  under  muscle  re-education. 
(X.  V.  Hospital  for  Deformities  and  Joint  Diseases.) 

Tuberculous  meningitis  will  he  indicated  by  a  flocculent 
fluid.  If  fluid  is  allowed  to  stand  twenty-four  hours,  a 
fibrin  network  will  form  and  be  plainly  demonstrable. 


198  INFANTILE    PARALYSIS. 

With  Heller's  test  for  albumin,  in  tuberculous  meningitis, 
the  percentage  of  albumin  will  be  high  and  a  thick  cloud 
will  form.  In  the  spinal  fluid  of  poliomyelitis  there  will  be 
<  >nly  a  faint  reaction  to  this  test. 

In  tuberculous  meningitis  the  bacillus  may  be  demon- 
strable, but  this  is  so  uncertain  that  its  absence  cannot  be 
c<  insidered  a  diagnostic  point. 

In  epidemic  cerebrospinal  meningitis  the  meningococcus 
will  be  found  in  the  centrifuged  sediment  of  the  spinal 
fluid. 

In  suppurative  meningitis  pus  will  be  present  in  the 
fluid. 

In  streptococcus  meningeal  infection  foll<  >wing  middle- 
ear  disease  there  will  be  a  clear  history  of  the  exciting 
cause. 

"Meningism  may  complicate  any  acute  contagion,  espe- 
cially bronchopneumonia.     Here  the  differential  diagnosis 
is  dependent  on  the  previous  history  of  the  case." 
phian.  ) 

Epidemic  Cerebrospinal  Meningitis. — Early  in  an  epi- 
demic of  poliomyelitis,  the  cases  of  an  encephalic  type  are 
mistaken  for  cases  of  epidemic  cerebrospinal  meningitis: 
and  this  is  not  surprising,  for  the  symptoms  of  the  vicious 
onset  are  the  same.  Koplik  suggests  as  a  point  of  distinc- 
tion that  in  polioencephalitis  there  is  a  short  preliminary 
period  in  which  the  patient,  having  had  a  high  fever,  con- 
tinues to  be  about.  Vomiting,  basilar  headache,  cervical 
rigidity,  high  temperature,  and  delirium,  with  or  without 
convulsions,  usher  in  the  Sttack  in  both  instances.  Isolation 
and  quarantine  are  recommended  while  making  a  study 
of  the  case.  \Yithout  examination  of  the  spinal  fluid,  it 
may  be  impossible  to  form  a  diagnosis  during  the  first 
forty-eight  or  seventy-two  hours.  The  second  or  third 
day,  the  characteristic  paralysis  is  apt  to  appear  in  cases 


199 

of  poliomyelit:  -  al  pals:-  epidemic  cere- 

brospinal  meningitis,  and  trans itory  and  late  with  high 
temperatu" 

The  temperature  in  epidemic  meningitis  is  high  at  onset 
and  remains  high  with  an  intermitting-  curve.  The  tem- 
perature of  polior  2  at  onset  and  declines  by 
crisis  before  onset  <~>f  par.. 

The  pulse  of  poliom  itremely  rapid  in  the 

prepare  _      ranging  from  1 10  to  200.    The  pulse  of 

eningitis  has  more  of  the  characteristics  of  the 

D  pulsC- 

Delirium  may  be  marked,  especially  in  sleep,  bcrt  will 

rn  with  the  improvemc  mptoms  in  the  one 

other  Ac  delirium,  though  broken  by  lucid 

interva.  -  -    _  :uporous  condition,  and  coma. 

Tlie  spastic  spine  in  cerebrospinal  meningitis  is  pathog- 

nomonic.    The  head  is  fixed  and  immovable.    In  poliomye- 

-  marked,  yet  the  patient  iiMK^f 
can  turn  his  head  from  side  to  side. 

Kernig's  sign  win  give  a  similar  reaction  in  each  leg  in 

-ebrospina!  -.-.  while  in  infantile  para- 

there  will  be  elicited  a  much  more  spastic  condition  in  one 
g    nan  in  the  other. 

Suppuratrre  Menimgitis. — In  meningitis  secondary  to 
pneumonia,  bnofytmji«ip*ininma^  middle-ear  disease,  or  the 
mening  lich  may  comphcate  any  acute  contagion, 

there  will  be  a  his:  ".ie  preceding  trouble. 

The  common  complication  of  middle-ear  trouble  fol- 
lowing influenza  or  grippe  should  be  kept  in  mind,  for  it 
precede  a  meningitis. 

^crculous  Meningitis. — In   tuberculous   meningitis 

the  condition  is  secondary  to  a  previous  infection,  and  the 

individual  and  familj     -        be  considered.     It 

occurs  alike  in  infants,  adolescents,  and  young  adults.    In 


200  INFANTILE    PARALYSIS. 

poliomyelitis  a  sudden  acute  onset  will  ensue  after  a  pre- 
vious state  of  perfect  health.  In  tuberculous  meningitis 
there  is  a  gradual  onset,  with  a  history  of  some  days  or 
weeks  of  malaise  and  temperature.  In  tuberculous  menin- 
gitis there  may  be  delirium,  convulsions,  followed  by  coma  ; 
this  also  may  be  seen  in  poliomyelitis,  but  in  the  former  case 
apathy  will  be  marked,  while  in  infantile  paralysis  there 
is  an  alert,  strained  look,  and  if  the  patient  falls  into  a 
semistupor  he  will  rouse  at  once  to  answer  a  question ;  will, 
in  fact,  react  to  his  surroundings  and  complain  of  many 
disturbing  factors,  such  as  a  ray  of  sunlight,  a  noise  on  the 
street,  the  jogging  of  his  bed,  to  which  the  sufferer  from 
tuberculous  meningitis  is  quite  indifferent. 

In  tuberculous  meningitis  the  spinal  rigidity  is  not  ex- 
treme, it  may  be  elicited  on  examination.  In  poliomyelitis. 
the  child  may  refuse  to  drink,  from  the  pain  engendered. 
A  little  girl  couldn't  "manage"  a  lemonade  straw,  and  it 
was  only  after  considerable  effort  and  the  bending  of  a 
glass  tube  that  she  could  be  induced  to  take  the  iced  drinks 
she  was  craving.  The  nursling  will  not  always  nurse  for 
the  same  reason;  the  bending  of  neck  or  any  movement 
of  head  is  too  painful. 

In  both  diseases  hydrocephalus  may  develop,  with  bulg- 
ing of  the  fontanels.  Cerebral  palsies  are  also  seen.  Local 
palsies  in  tuberculous  meningitis  are  usually  transitory  and 
shifting.  They  are  said  to  be  due  to  the  shifting  of  the 
fluid  in  the  ventricles,  and  may  occur  in  face,  arms  or  legs. 
The  paralyses  of  poliomyelitis  are  not  shifting  or  transi- 
tory ;  some  mild  cases  develop  only  a  paresis,  which  rapidly 
clears,  but  these  cases  are  of  so  mild  a  character  that  there 
is  no  danger  of  confusing  them  with  tuberculous  meningitis. 

The  temperature  in  tuberculous  meningitis  is  charac- 
teristic; afternoon  rise  to  103°  F.,  and  in  the  late  stages  a 
high,  intermitting  range.  Poliomyelitis  of  the  cerebral 


DIFFERENTIAL    DIAGNOSIS. 


201 


type  begins  with  a  high  temperature,  which  rapidly  sub- 
sides, and  remains  within  one  degree  of  the  normal 
throughout  the  illness. 

The  mental  state  of  the  patient  in  the  polioencephalic 
form  of  poliomyelitis  is  perhaps  the  most  decided  diag- 
nostic point.  The  delirium  or  stupor,  if  present,  lightens, 
and  the  patient  proceeds  to  recover.  They  do  not  seem  to 
i^e  suffering  from  brain  disease.  A  case  in  the  Connecti- 
cut epidemic,  with  a  complete  hemiplegia,  developed  an 
aphasia  on  the  fifth  day,  but  "looked  bright."  (Sophian.  i 

Mcningisui  in  Infectious  Diseases. — Meningcal  phe- 
nomena may  supcrrcnc  as  the  sequence  of  toxic  influences 
on  the  central  nervous  system,  with  no  change  in  the 
meninges.  Typhoid  fever,  pneumonia,  and  other  acute  in- 
fectious diseases  may  produce  this  intoxication,  which  is 
manifested  as  a  meningism.  There  is  no  change  in  the 
spinal  fluid,  nor  demonstrable  alteration  in  the  meninges. 

Suppuratiue  Meningitis. — In  meningitis  secondary  to 
pneumonia,  bronchopneumonia,  middle-ear  disease,  or  the 
meningism  which  may  complicate  any  acute  contagion, 
there  will  be  a  history  of  the  preceding  trouble.  The 
common  complication  of  otitis  media  following  influenza 
or  grippe  should  be  kept  in  mind,  for  it  may  precede  a 


meningitis. 


DIFFEREXTIAL  DIAGNOSIS. 


Poliomyelitis,  cere- 
bral type,  with  or 
without  meningitis. 

Season  Maximum,  late 

summer. 

History1    Presence  of 

epidemic  in 
community. 
Hist,  of  ex- 
posure. 


Cerebrospinal 
meningitis. 

Winter  and  spring. 


Presence  of  epi- 
demic. 


Tuberculous 
meningitis. 


Tub.  infection  of 
patient  or  family. 


1  The  history  of  suppurative  meningitis  is:    Otitis  media;  mastoiditis; 
sinus  infection. 


?02 


INFANT ILK    PARALYSIS. 


DIFFKRF.XT1AL  DIAGNOSIS  (Concluded). 


Poliomyelitis,    cere- 
bral   type,    with    or 

without  meningitis. 

Nutrition     Healthy,   robust 

and  active. 
Onset    Acute. 

Pulse    Rapid,  120-200. 

Temperature    . . .  High,  1  to  4  days, 
declining  by  crisis 
as  paralysis  ap- 
pears. 

Mental  state  . . .  Excitable,  star- 
ing. 

I'.owels  Paresis  and  ob- 
stipation. 

Skin    Multiform    rash. 

Cervical  rigidity.  Present,  but   can 
move  head   from 
side  to  side. 

Kernig's  sign  ...One   leg  much 

more  spastic  than 
other. 

Local  palsies  . . .  Characteristic  : 
regressive   but 
not  transitory. 
I  lead,  trunk,  or 
extremities. 

Delirium    During    sleep    and 

ceases  with  on- 
coming of  paral- 
ysis. 

Tremor    Marked. 

Spin?.!  fluid Increased  pres- 
sure.    No  organ- 
•isms. 

Clear  or  a  slight 
shimmering.      N« 
fibrin  clot. 
ITvpoleucocytosis. 
(Lymphocytes 
90%.) 

Albumin,  a  trace, 
and  protein. 


Cerebrospinal 
meningitis. 

Impaired. 


Acute. 


Tuberculous 
meningitis. 

Impoverished. 


Gradual    (early 
stage  slow  ) . 

Slow.  Moderately    rapid. 

High    from   onset:      Characteristic 
intermitting  KM.  rise:  high, 

curve.  intermitting 

range  in  late 
stages. 
Stupcrose.  Apathy    marked. 


Rash.     Herpes. 

I  lead  fixed  and 
immovable. 

Kqual    in    the    two 
legs. 

Rare.     Face  or 
eves  onlv. 


With  lucid  inter- 
vals. 


Meningococcus. 
Turbid.      Albu- 


Xo  rash.     X<>  her- 
pes. 
Not  marked. 


Transitory  of 
fare.    arms.    lci;s. 


Delirium,    fol- 
lowed  by   con- 
vulsions and 
coma. 

Koch's   bacillus. 
Turbid,  floccu- 
lent.     Albumin  ' , 
high.      Fibrin    ' ; 
high. 


DIFFKKKXTIAL    DIAGXOS1S. 


203 


Other  Diseases  of  the  Cerebrospinal  .l.vis,  With  or 
ll'ithont  Paralysis. — The  confusing  nomenclature  of  acute 
nervous  diseases  varies  widely  in  the  accepted  textbooks. 
It  is  evident  to  the  mere  student  pathologist  that  indicative 
symptoms  have  been  classified  and  described  as  separate 
diseases.  The  cerebrospinal  axis  is  the  most  highly  de- 
veloped and  specialized  organ  known  to  man.  A  large 


Fig.  64. — Facial  paralysis  in  23 
months'  infant  referred  as  a  case 
of  infantile  paralysis.  F'uther  died 
;it  _'d  years.  Infant  developed  typical 
syphilitic  eruption  on  legs.  (X.  Y. 
Hospital  for  Deformities  and  Joint 
Diseases.) 


Fig.  65. — Acute  bulbar  type  with 
paralysis  of  facial  nerve.  (X.  Y. 
Hospital  for  Deformities  and  Joint 
Diseases.) 


class  of  ihe  manifold  lesions,  ranging  from  a  mild  pressure 
edema  to  necrosis,  which  may  occur  in  any  one  of  its 
intricate  parts,  disturbing  one,  or  any  possible  combination, 
of  its  functions  (which  govern  and  induce  every  voluntary 
and  involuntary  act  relating  to  life),  may  have  been  in- 
cited bv  one  unknown  destructive  infection. 


204  1XFAXTILE    PARALYSIS. 

l:riedreiehs's  .Ita.via. — "Often  attacking  several  chil- 
dren in  the  same  family."  May  prove  to  be  hereditary  only 
in  the  sense  with  which  today  we  explain  how  pulmonary 
tuberculosis  appears  and  reappears  in  a  family,  from  suc- 
cessive series  of  reinoculations.  This  ''hereditary  disease" 
develops  most  frequently  in  childhood  and  at  the  age  of 
puberty,  or  during  the  susceptible  period  for  contracting 
an  infection. 

I \iralysis  .  Igitans. — A  tremor  of  the  extremities  in  the 
aged  following  "the  exhaustion  of  an  acute  disease,"  and 
-ucceeded  by  rigidity,  contractures,  and  atrophy.  \Yhat 
would  result  from  the  shock  of  an  infection  of  the  cerebn  »- 
spinal  axis  not  sufficiently  grave  to  paralyze  or  kill  ? 
\Yould  it  not  have  a  tendency  to  precipitate  and  exaggerate 
those  symptoms  of  senility,  tremor,  ataxia,  and  inco-ordi- 
nation  in  men  or  women  well  past  life's  meridian?  And 
does  it  not  leave  ample  proof  of  its  antecedent  cause  in  the 
muscular  weakness,  rigidity,  contractures,  and  atrophy? 

Acute  Transverse  Myelitis. — Ushered  in  by  fever, 
headache,  delirium, — abruptly  with  a  convulsion, — by  rheu- 
matoid pains, — retention  of  urine  (a  very  important  and 
early  symptom), — and  a  possible  spastic  paraplegia,  form 
so  clear  a  group  picture  of  the  onset  and  progress  of  a  ca-e 
of  poliomyelitis  with  lumbar  involvement  only,  that  a  differ- 
ential diagnosis  is  hardly  in  order.  Landry's,  or  the  acute 
ascending  paralysis  of  the  textbooks,  is  now  known  to  be 
a  mere  variation  in  the  mode  of  attack  of  poliomyelitis 
epidemica  acuta. 

It  is  questionable  whether  myelitis  is  essentially  different  in 
etiology  from  poliomyelitis.  The  symptoms  differ  merely  because 
in  the  former  more  of  the  transverse  area  of  the  cord  is  involved. 
1  have  observed  myelitis  in  an  adult  which  developed  last  year  during 
the  epidemic  of  poliomyelitis,  and  it  has  occurred  to  me  that  possil>l\ 
this  case  was  a  manifestation  of  poliomyelitis.  (  Spiller. ) 


DIFFEREXTIA1.    DIAGNOSIS.  205 

Diseases  Presenting  I'aralytie  Conditions:— 

Diphtheritic  paralysis — diphtheria.  Hysterical  paralysis. 

Syphilitic  pseucloparalysis.  Pseudoparalysis  of   scurvy. 

Tuberculous   spondylitis   with   pa-  Occupation  neurosi-. 

ralysis.  Progressive  muscular  atrophy. 
<  >l»tetrical  paraly-U. 

Diphtheria  and  Diphtheritic  Paralysis. — The  onset  of 
acute  epidemic  paralysis  is  sometimes  announced  by  a 
pharyngeal  angina  of  so  severe  a  decree  that  a  diagnosis  of 

diphtheria  has  been  made. 

Lillian  B.,  Eau  Claire,  \\  is.,  10  years  old,  September,  1908 
(  during  epidemic  )  ;  membranous  sore  throat.  Antitoxin  given.  At 
the  end  of  one  week  of  fever,  delirium,  prostration,  right  arm  be- 
came paralyzed,  then  left ;  paralysis  gradually  extending  to  muscles 
of  respiration,  patient  died  on  the  twelfth  day  of  illness.  Diagn<»i- 
changed  to  infantile  paralysis  on  appearance  of  characteristic 
paralysis.  (Ashum.) 

Diphtheria. — Enlarged  cervical  glands,  absence  of  knee-jerk. 
-lower  pulse  at  onset  (100  to  120),  membrane  attached,  of  appre- 
ciable thickness,  Klebs-Loffler  bacillus.  Paralysis  postdiphtheritic, 
manifested  by  nasal  intonation,  regurgitation  of  liquids  through  nose, 
and  inco-ordinate  movements,  which  appear  late. 

lipidcmic  Paralysis. — Xo  enlargement  of  cervical  glands;  ex- 
aggerated knee-jerk;  rapid  pulse  at  onset  (120  to  200),  patches  on 
throat  isolated  and  superficial ;  paralysis  usually  of  extremities  first. 

In  true  multiple  neuritis  the  course  of  the  disease  is  slower, 
the  early  febrile  stage  is  absent,  the  palsy  is  usually  symmetric  and 
greater  in  peripheral  parts.  Poliomyelitis  may  begin  with  angina 
and  thus  suggest  diphtheritic  neuritis,  but  the  paralysis  follows  the 
angina  much  later  in  diphtheritic  multiple  neuritis.  There  is  not 
likely  to  be  paralysis  of  the  soft  palate  and  of  accommodation,  or 
cardiac  symptoms  in  poliomyelitis,  and  these  are  common  after  diph- 
theria. Multiple  neuritis  is  believed  by  some  to  be  more  common 
in  children  than  has  been  taught.  (Spiller. ) 

Sypliilitie  Pseudoparalysis. — Absence  of  knee-jerk  is 
characteristic  of  locomotor  ataxia,  and  appears  before  the 


206  1XFAXTILE    PARALYSIS. 

inco-ordination  of  gait;  there  is  also  a  preceding  history  of 
venereal  infection,  and  gradual  onset. 

l:.t>idcmic  Paralysis. — The  knee-jerk  is  exaggerated  during  on- 
set of  disease.  Confusion  may  arise,  when  an  adult  male  with  an 
admitted  venereal  infection,  dates  a  slowly  progressive  ataxia,  inco- 
ordination,  and  mental  bewilderment  from  a  certain  "spell"  of  two 
days'  illness  occurring  when  acute  paralysis  was  epidemic  in  com- 
munity. 

Luctic  pseudoporalysis  of  infancy  is  due  to  an  acute  epiphysitis, 
and  will  be  associated  with  characteristic  skin  lesions,  etc.,  which 
will  yield  to  mercurial  treatment,  and  confirm  diagnosis. 

The  general  consensus  of  opinion  is  that  syphilis  is  not  a  general 
factor  in  the  upper  neuron  paralysis  of  childhood,  and  this  opinion 
appears  to  be  based  on  very  good  grounds.  Nevertheless,  a  recon- 
sideration of  the  part  syphilis  plays  may  be  instructive  and  appears 
to  be  desirable  for  two  reasons :  First,  because,  in  some  cases  at 
least,  a  permanent  and  crippling  disability  of  both  body  and  mind 
may  be  prevented  by  an  intelligent  anticipation  of  events ;  and. 
secondly,  because,  thanks  to  the  methods  of  diagnosis  perfected  of 
late  years,  it  may  yet  turn  out  that  syphilis  is  a  more  important 
factor  in  the  production  of  these  paralyses  than  many  have  sus- 
pected. 

Tuberculous  Spondylitis  With  Paralysis. — The  gradual 
onset  of  the  condition,  and  the  vertebral  knuckle  are  char- 
acteristics of  tuberculous  disease  of  the  spine  which  has 
advanced  to  the  stage  of  pressure  paralysis.  Paralysis  may 
be  transitory  when  collateral  pressure  edema  is  relieved. 

Obstetrical  Paralysis.  —  ''Obstetrical  paralyses  arc 
limited  to  traumatized  nerve-trunks,  and  are  found  usually 
in  the  parts  likely  to  be  handled  with  violence  1>\  the  obste- 
trician— namely,  the  shoulders  and  arms."  (Hummel.) 

These  cases  when  brought  to  the  specialist  usually  give 
a  clear  history  of  birth  palsy  following  difficult  labor.  Tf 
the  labor  was  not  protracted  nor  otherwise  difficult,  it  would 
be  well  to  keep  in  mind  the  possibility  of  an  intra-uterine 
poliomyelitis  or  encephalitis. 


D1FI-KKKXTIAL    Dl.UiXOSIS.  207 

Hysterical  Paralysis. — Poliomyelitis  in  its  chronic  form 
may  be  simulated  by  an  hysteria,  "but  the  symptoms  in 
purely  functional  cases  do  not  group  themselves  usually 
in  a  manner  typical  of  infantile  paralysis."  Hysterical 
deformity  or  contracture  can  be  temporarily  overcome  by 
anesthetizing  the  case. 

Pseudo paralysis  of  Scurry. — This  condition  is,  happily, 
extremely  rare  in  the  Northern  States  and  usually  insti- 
tutional. According  to  Fenner,  of  Xew  Orleans,  this  con- 
dition is  not  a  rare  disease  among  artificially  fed  children 
of  the  well  to  do  in  the  South,  and  "paralysis  is  another 
common  mistake  in  diagnosis."  The  differential  diagnosis 
would  relate  to  the  hemorrhagic  and  spongy  gums,  hemor- 
rhages into  the  orbit,  hematemesis,  bloody  urine,  and  the 
immediate  response  to  antiscorbutic  diet:  fruit  juices, 
oranges,  lemon,  pineapple  and  fresh  food. 

Muscular  dystrophy  could  be  considered  only  in  the  late  stages 
of  poliomyelitis,  and  at  this  period  confusion  is  possible.  I  have 
seen  cases  in  which  the  differential  diagnosis  was  difficult.  (Spiller.) 

.  I  cute  Infectious  Diseases  ll'ithout  Paralysis: — 

Enteritis.  Measles. 

Typhoid.  German  measles. 

Rheumatism.  Scarlet   fever. 

Tonsillitis.  Chicken-pox. 

Influenza — summer  grippe.  Tetanus. 

Pneumonia.  Rabies. 
Pleurisy. 

Summer  Diarrhea — Enteritis,  Cholera  Morbus. — The 
f<  flowing  table,  compiled  by  Dr.  H.  W.  Hill,  epidemiologist, 
Minnesota  State  Board  of  Health,  which  he  denominates 
an  "interesting  analogy  by  contrast,"  is  given  in  the  belief 
that  nothing  could  more  clearly  demonstrate  the  lack  of 
relationship  between  infantile  enteritis  and  epidemic 
paralysis: — 


208  1XFAXT1LE    PARALYSIS. 

Summer  diarrhea.  Anterior  poliomyelitis. 

Weather    Hot.  damp.  Hot,    dry. 

Onset   Slow.  Abrupt. 

Age    Under  2  years.  Over  2  years. 

Feeding   Overfeeding.  Underfeeding. 

Bowels    Diarrhea.  Constipation. 

Previous  health  ....  Poor.  Good. 

Incidence Slum  dweller-.  Rural  dwellers. 

Elimination    Marked.  Retention. 

Dietetic  errors    ....Continuous  Accidental    or    absent 

(except  deficiency  i. 

Intestinal  incidence. Marked.  Slight. 

Nervous  incidence.  .Slight.  Marked. 

Relation  to  milk.  .  .Obvious.  Xone. 

The  following  death  certificates  are  taken  from  the 
records  of  Eau  Claire,  \Yis.,  during  the  period  poliomyelitis 
was  epidemic  there,  July,  August,  and  September,  1908. 
In  each  case  there  was  one  or  more  cases  of  clearly  marked 
paralysis  in  house  or  immediate  neighborhood:— 

Cause  of  death. 

July  7th,  Male,    I  year  4  mos.,      "Convulsions   due    to   enteritis." 
July  24th,  Female,  7  years.  "Congestion  of  brain." 

Aug.  i6th,  Male,  9  years,  "Paralysis  of  heart." 

Aug.  28th,  Male,  18  mos.,  "Acute  indigestion/' 

Sept.  5th,  Male,  4  years,  "Enterocolitis.      congestion      of 

brain." 

It  seems  probable  that  in  other  communities  a  certain 
percentage  of  deaths  due  to  poliomyelitis  arc  thus  credited. 
Vomiting  and  prostration  are  the  only  symptoms  common 
to  both.  The  seasonal  occurrence  is  identical,  but  thi^ 
probably  indicates  only  that  the  transmission  of  the  two 
diseases  is  dependent  on  insect  carriers,  whose  numbers 
increase  largely  in  summer. 


DIFFERENTIAL    DIAGNOSIS.  209 

Typhoid  fever.  Poliomyelitis. 

Onset  Insidious.  Acute. 

Season Fall.  Summer. 

Fever    Continuous.  Early  fall  by  crisis. 

Rash  Rose  spots  on  abdomen.  Scarlatiniform,  blotchy,  or 

petechial  and  pustular 
over  trunk  and  extremi- 
ties. 

P>o\vels    ....Diarrhea,  pea-soup  stool.      Constipation. 

Appetite  . . .  Anorexia.  Hungry  when  tempera- 

ture lowers,  3-4  day. 

Pulse   Slow  pulse  characteristic.      Much  augmented,   100  to 

200. 

Ijlood    \Yidal  reaction.  YVidal  negative. 

Paralysis   . . .  None.  Characteristic. 

Spasticity  . .  Not  present.  Cervical   or   entire   spine. 

The  early  symptoms  which  might  lead  to  a  tentative 
diagnosis  of  typhoid  fever  in  a  case  of  poliomyelitis  are  the 
epistaxis,  the  extreme  prostration,  temperature,  delirium, 
tremor,  twitching  and  severe  continued  headache,  and 
meteorism. 

A  rapid  pulse,  nuchal  rigidity,  and  constipation  would 
speak  almost  certainly  for  poliomyelitis.  Season  and  pres- 
ence of  epidemic  in  community  should  be  considered. 

Paratyphoid. — The  mode  of  onset  alone  would  indicate 
diagnosis. 

Rheumatism,  Acute,  Articular,  and  Muscular. — In  the 
carefully  investigated  symptomatology  of  19  cases  of  polio- 
myelitis, Dr.  Shidler  reports  (Nebraska  State  Medical 
Association)  that  all  but  I  case  suffered  from  general 
tenderness.  This  agonizing  tenderness,  taken  with  the 
fever  and  prostration,  probably  accounts  for  the  mistaken 
diagnoses  of  rheumatism.  In  rheumatism  there  is  often 
a  history  of  previous  attacks  which  salicylates  have  re- 

14 


210  I M- AX  TILE    PARALYSIS. 

lieved;  there  is  swelling"  and  redness  of  the  joints,  and  the 
pain  in  the  joints  is  severe  in  the  early  stage.  In  poliomye- 
litis the  pain  corresponds  more  nearly  to  the  distribution  of 
great  nerve-trunks,  and  increases  after  the  fever  begins  t<  > 
decline.  There  is  not  usually  any  swelling  of  the  joints  in 
poliomyelitis,  yet  this  has  been  noted  by  a  few  observers. 

The  affected  limb  in  poliomyelitis  is  cold  to  the  touch, 
and  distinctly  cyanosed,  assuming  a  dull-reddish,  purple 
hue. 

Muscular  Rheumatism. — A  localized  myalgia,  such  as 
torticollis,  pleurodynia  or  lumbago,  usually  appears  as  a 
spontaneous  symptom  or  condition  unrelated  to  an  attend- 
ant or  subsequent  train  of  illness.  In  torticollis  the  head 
will  be  inclined  toward  the  affected  sternocleidomastoid 
muscle,  and  the  spasm  will  disappear  with  catharsis  and 
the  application  of  heat. 

Tonsillitis. — Cases  have  been  diagnosed  as  tonsillitis 
due  to  swelling  and  inflammation  of  the  tonsils,  which,  in 
an  exceptional  case,  was  reported  extreme.  If  the  mucous 
membrane  of  nose  and  throat  forms  the  point  of  attack  f<  >r 
the  virus,  it  is  not  strange  that  the  tonsils  sometimes  react 
markedly ;  this  is  the  exception  and  not  the  rule. 

A  true  tonsillitis  will  usually  give  a  history  of  suscepti- 
bility and  repeated  attacks,  with  allied  rheumatic  condi- 
tions. The  meningism  that  accompanies  a  severe  attack  of 
tonsillitis  will  be  confusing.  This  meningism  usually  clear- 
promptly  on  the  exhibition  of  calomel. 

Tonsillitis.  Poliomyelitis. 

History   Repeated  attacks.  Xone. 

Rheumatic  attacks.  Xone. 

Onset   Chill.  Rare. 

Tremor   Xone.  l"-ual. 

Rash   .  .  Xone.  I'-nial. 


DIFFERENTIAL    DIAGNOSIS.  211 

Influenza — Summer  Grippe. — Influenza,  grippe,  and 
the  balance  of  the  respiratory  diseases  reach  their  period 
of  maximum  incidence  in  February  and  March.  When 
they  appear  during  the  summer  they  usually  follow  a  period 
of  damp  and  cold  weather  and  are  more  apt  to  affect  adults. 
The  coryzal  onset  of  influenza  is  rarely  seen  in  poliomye- 
litis. Dr.  C.  A.  Anderson,  of  Stromsberg,  Nebraska, 
reports  "complete  absence  of  acute  catarrhal  trouble  in  the 
respiratory  tract  and  eyes,"  in  an  analysis  of  279  cases  in 
the  Polk  County  epidemic. 

Pneumonia,  Bronchopncumonia. — Rapid  and  shallow 
respirations,  together  with  the  abrupt  onset,  high  tem- 
perature and  racing  pulse,  suggest  an  impending  bron- 
chopneumonia  when  the  child  is  first  seen.  There  is 
sometimes  an  accompanying  bronchitis,  but  this  is  rare. 
Physical  examination  will  show  the  lungs  are  clear. 

The  respirations  may  reach  or  exceed  60  per  minute 
for  the  first  day  of  onset,  with  no  apparent  cause,  and  then 
slow  down  to  normal ;  this  may  occur  in  the  ordinary  lower- 
segment  type  paralysis  with  no  extension,  or  the  mild  cases 
with  paresis  only.  This  acceleration  may,  however,  an- 
nounce the  onset  of  a  case  of  the  ascending  type  of  paralysis 
with  beginning  involvement  of  the  muscles  of  respiration. 

Measles,  German  Measles,  Scarlet  Fever,  Chicken-pox. 
—Skin  rashes  which  follow  the  fastigium  of  poliomyelitis 
may  simulate  the  eruption  of  any  one  of  the  acute  exanthe- 
mata. A  scarlatinal  blush,  a  fine  petechial  rash,  measly 
blotches,  and  a  papular  and  vesicular  eruption  have  all  been 
observed.  The  measly  rash  with  blotches  somewhat 
smaller  than  in  measles  is  most  common,  and  has  doubtless 
been  efficient  in  scattering  the  infection  of  poliomyelitis  far 
and  wide.  Many  mothers  are  convinced  that  it  is  better  for 
children  to  ''take"  measles  when  they  are  young,  and  are 
not  averse  to  allowing  them  to  play  with  supposed  cases  of 


219  1XFAXT1LE    PARALYSIS. 

measles.  In  German  communities  there  are  always  gute 
Hausfrauen  who  are  considered  sufficiently  accurate  diag- 
nosticians for  such  trifling  ailments. 

Measles  will  have  a  history  of  an  acute  coryza  with 
watering  eyes,  cough,  diarrhea  (usually), — in  fact,  an 
acute  catarrhal  inflammation  of  the  mucous  membranes  of 
digestive  and  respiratory  tracts;  while  in  poliomyelitis  in 
an  early  stage  the  eliminations  are  nil.  In  severe  cases  of 
measles,  especially  in  adults,  there  is  a  pronounced  menin- 
gism  at  onset,  followed  by  an  apathetic  typhoid  condition. 
The  meningitis  of  poliomyelitis  is  of  a  much  more  pro- 
nounced type ;  the  spastic  spine,  augmented  reflexes,  basilar 
headache,  will  serve  to  differentiate  the  two  diseases;  a 
history  of  the  epidemic  appearance  of  one  or  both  in  the 
community  must  be  considered. 

The  rash  of  measles  usually  appears  on  the  face,  at  the 
edge  of  the  hair  and  back  of  the  ears ;  the  rash  of  poliomye- 
litis,- on  trunk  and  extremities. 

German  Measles. — The  eruption  of  German  measles 
also  appears  usually  on  the  face  and  below  hairline.  There 
is  an  accompanying  coryza,  and  enlargement  of  cervical 
and  occipital  glands,  which  will  serve  to  differentiate  it 
from  poliomyelitis. 

Scarlet  Fever.- — There  is  little  danger  of  confusing  a 
typical  case  of  scarlet  fever,  for  the  brilliant  scarlet  blush 
appears  early,  usually  at  the  lapse  of  twelve  hours.  The 
rash  of  poliomyelitis,  which  may  assume  the  scarlatinal 
type,  appears  late,  as  the  fever  is  declining. 

Chicken-pox. — The  diagnosis  in  the  following  cases 
was  carefully  reconsidered  on  the  appearance  of  a  pustular 
rash.  The  cases  occurred  during  the  apogee  of  the  epi- 
demic of  1908  in  Eau  Claire,  Wis.,  and  were  seen  in 
consultation : — 


DIFFERENTIAL    DIAGNOSIS.  213 

B.  and  \Y.,  brothers,  aged  2  and  7  years,  taken  sick  forty-eight 
hours  apart;  marked  prostration,  twitching,  abolished  reflexc-. 
inability  to  rai^e  head,  moderate  fever  (102°);  rapid,  running, 
feeble  pulse;  entirely  conscious.  Paralysis  of  respiration  terminated 
both  cases  the  succeeding  Sunday  afternoon,  the  third  and  fifth  day 
after  attack,  the  baby  dying  at  3  P.M.  and  the  older  buy  at  7  P.M. 
The  pustular  rash  appeared  all  over  torso  and  extremities  of  babe. 
The  environment  was  most  unsanitary. 

Tetanus  U'itli  Convulsions. — A  poliomyelitis  of  Lan- 
drv's  descending  type  might  closely  simulate  an  attack  of 
lockjaw,  and  the  history  of  a  recent  slight  trauma  would 
tend  to  confuse  the  diagnosis. 

S.  M.,  of  Wisconsin,  14  years  of  age,  was  present  in  a  group 
of  other  boys,  on  the  morning  of  the  4th  of  July,  when  a  toy  cannon 
exploded.  He  was  struck  by  one  of  the  flying  particles  and  sus- 
tained a  slight  laceration.  Late  in  the  month  he  became  ill  with 
convulsions,  and  a  diagnosis  of  tetanus  was  made  by  the  attending 
physician.  Antitetanic  serum  was  telegraphed  for,  but  paralysis  of 
all  extremities  followed  before  it  could  be  used.  This  was  not  a 
fatal  case.  \Yhen  last  seen,  a  year  subsequent  to  the  attack,  he  was 
a  helpless  paralytic,  with  general  atrophy  of  rnuscles. 

The  history  of  a  trauma,  in  a  case  of  convulsions  with 
spastic  condition  of  the  facial  muscles,  is  not  today  pre- 
sumptive evidence  of  the  presence  of  tetanus.  In  a  large 
percentage  of  cases  of  frank  poliomyelitis  there  is  a  clear 
history  of  a  trauma,  frequently  accompanied  by  a  solution 
of  continuity.  The  trauma  is  most  frequently  due  to  a 
stumble,  slip  or  fall,  the  result  of  the  inco-ordination  which 
accompanies  the  onset  of  this  disorder  of  the  cerebrospinal 
axis. 

An  adult  male  38  years  of  age,  while  making  stump 
speeches  through  a  country  district  where  poliomyelitis 
was  epidemic,  ran  to  catch  a  trolley  car,  stumbled,  fell,  and 
-cratched  his  knee.  He  was  taken  ill  the  following  day, 
treated  for  lock-jaw  and  promptly  died.  The  sequence  of 
onset  of  the  acute  disease,  inco-ordination,  fall,  and  trauma 


214  INTAXT1LK    PARALYSIS. 

is  indubitably  more  probable  than  that  tetanus  followed 
so  promptly  on  a  slight  open  wound,  and  was  utterly  un- 
responsive to  antitetanic  serum,  which  was  administered. 
Cases  of  poliomyelitis  occurring  within  a  few  weeks 
of  the  4th  of  July,,  have  been  mistakenly  attributed  to  lock- 
jaw resulting  from  some  quite  harmless  burn  from  fire  or 
cannon  cracker.  Every  such  case,  improperly  diagnosed, 
remains  a  menace  to  the  community  unprotected  from  con- 
tagion. 

Tetanus.  Poliomyelitis. 

Trauma  ....  Injury   not   recent ;   pres-      History  of  trauma  prob- 
ence  of  visible   wound.          able  and  recent. 

Onset Seven    to    fourteen    days      Onset    coincidental     with 

after  injury.  trauma  or  within  forty- 

eight  hours. 

Course Karly  involvement  of  mas-      Masseter     muscle     rarely 

seter.  involved. 

Headache   ..  Xo  headache.  I'.a>ilar  headache   intense. 

Inferior 

maxilla   ..  Lower  jaw  fixed  and  im-      Patient  can  depress  lower 
movable.  maxilla      to      sternum. 

though  cervical  rigidity 
is  marked. 

Rabies. — Most  children,  if  not  allowed  a  pet  of  their 
own,  have  established  friendly  relations  with  the  dog  or 
cat  belonging  to  a  neighbor.  Much  rough  and  amiable 
frolicking  results,  and  any  observer  may  assure  himself 
that  it  is  not  often  the  child  who  is  the  victim  of  this  rough 
and  tumble  sport.  An  acute  and  fatal  illness,  characterized 
by  convulsive  seizures  with  a  history  of  having  been 
scratched  or  bitten  by  some  household  pet,  is  not  neces- 
sarily rabies. 

On  the  other  hand,  there  has  been  an  astonishing  in- 
crease in  the  newspaper  report  <  of  deaths  from  hydro- 
phobia since  poliomyelitis  became  pandemic  in  Xorth 
America.  Tt  may  lie  that  the  curious  and  unexplained 


DIFFERENTIAL    DIAGNOSIS. 


215 


analogy  of  these  two  diseases  will  not  always  remain  ob- 
scure. The  physician  today  should  be  able  to  definitely 
eliminate  the  possibility  of  the  presence  of  acute  epidemic 
paralysis  before  making  a  diagnosis  of  rabies. 


History 


Rabies. 

.Bite  or  laceration,  from 
rabid  dog.  cat,  fox. 
wolf,  or  skunk. 


Incidence 

Premonitory 
symptoms   . 


Incubation     from 
to  sixty  days. 


tortv 


1  )y-])hagia   .  . . 


Itching  or  burning  of 
wound,  with  renewed 
inflammation. 

Pharyngeal  spasm,  sali- 
vation. 

Due  to  pharyngeal 
spasm,  intractable. 


Spasticity    Paroxysmal. 


Poliomyelitis. 

None,  or  scratch  or  play- 
ful bite  from  house- 
hold animal  with  un- 
impaired health. 


Wound  healed  and  in- 
visible. 

Xo  pharyngeal  spasm ; 
no  salivation. 

Difficult  swallowing  due 
to  cervical  rigidity 
and  pain.  Overcome 
by  use  of  drinking 
cup ;  tonic ;  unrelaxing. 

Tonic    and     unrelaxing. 


DENTITION,    AUTOINTOXICATION,    PTOMAINE 
POISONING,  ECLAMPSIA,  TRICHINIASIS. 

Dentition. — The  error  of  an  assumed  relationship  be- 
tween acute  epidemic  paralysis,  and  the  period  of  dentition, 
apparently  dates  back  to  the  report  of  Dr.  George  Cornier 
of  cases  occurring  in  \Yest  Feliciana,  La.,  in  the  summer 
of  1841.  In  this  first  report  of  the  disease  in  its  epidemic 
form.  Dr.  Colmer  states  that  12  cases  were  all  teething 
children  under  2  years  of  age.  Two  errors  seem  to  have 
taken  their  origin  from  this  otherwise  illuminating  report: 
first,  that  this  epidemic  malady  was  one  of  infants  only, 
and,  second,  that  it  related  to  the  period  of  dentition. 


216  INFANTILE    PARALYSIS. 

Dentition  is  included  in  the  differential  diagnosis  for 
the  reason  that  among  the  laity,  and  also  some  of  the  pro- 
fession, it  has  been  loosely  stated  that  infantile  paralysis 
was  a  complication  of  teething,  whose  results  may  be  and 
usually  are  outgrown.  A  Manhattan  father  was  so  in- 
formed when  his  i8-nionth-olcl  daughter  developed  a  com- 
plete paraplegia. 

The  eruption  of  the  teeth  in  childhood  is  usually  marked 
by  hypersecretion  of  the  saliva,  with  drooling,  and  an 
enterocolitis  with  diarrhea.  The  lowering  of  the  child's 
resistance  would  make  it  more  susceptible  to  exposure  from 
any  infection,  and  therein  lies  all  relationship  between 
teething  infants  and  acute  epidemic  paralysis.  The  onset 
of  poliomyelitis  is  usually  accompanied  by  an  obstinate 
constipation. 

Autointoxication. — Intestinal  intoxication  with  re- 
tarded elimination  and  meningism  may  simulate  the  onset 
of  poliomyelitis.  Elevated  temperature,  increased  pulse 
rate,  basilar  headache,  vomiting,  vertigo,  and  even  a  mild 
delirium  or  confusion  may  be  all  present.  The  immediate 
relief  given  by  a  thorough  flushing  of  the  bowels  will  serve- 
to  differentiate  the  condition  from  the  disease. 

Ptomaine  Poisoning. — The  furious  onset  which  usually 
accompanies  an  attack  of  poliomyelitis  in  the  adult,  may 
easily  be  mistaken  for  a  case  of  ptomaine  poisoning  from 
the  ingestion  of  decomposed  food.  A  rapid,  irregular,  and 
feeble  pulse,  projectile  vomiting,  meteorism,  and  symp- 
toms of  basilar  irritation,  or  stupor,  are  common  to  both 
conditions.  In  ptomaine  poisoning  the  history  will  be  of 
an  indiscreet  diet,  of  the  partaking  of  some  one  article  of 
food  after  which  the  patient  immediately  felt  unwell,  or  of 
some  article  for  which  he  has  always  had  an  individual 
susceptibility.  There  may  be  a  history  of  the  simultaneous 
illness  of  several  members  of  the  same  party  which  had 


DIFFEREXTIAL    DIAGNOSIS.  217 

eaten  of  the  dish,  which  would  clinch  the  diagnosis.  La- 
vage  of  the  stomach,  calomel  and  a  colonic  flushing  will 
relieve  the  vomiting,  and  the  other  symptoms  will  gradually 
modify,  in  a  case  of  ptomaine  intoxication. 

The  sudden,  forcible,  repeated  vomiting  of  poliomye- 
litis when  present,  being  central  in  origin,  will  not  yield  to 
stomach  lavage,  nor  will  the  symptoms  of  basilar  irritation 
modify  immediately  under  this  treatment.  There  have 
been  undoubted  cases  during  the  epidemic  disease  which 
were  supposed  to  be  due  to  intestinal  irritation,  with  an 
extremely  severe  onset,  which  cleared  up  under  the  treat- 
ment outlined,  with  no  remaining  paralytic  complication, 
where  the  true  cause  of  the  attack  would  have  been  un- 
known and  unsuspected,  had  not  another  member  of  the 
household  subsequently  sickened  with  a  typical  case  of 
poliomyelitis. 

Poliomyelitis.  Ptomaine  poisoning. 

Epidemic  in  community.  No  epidemic. 

History  of  exposure.  Not  exposed. 

Xo  dietary  indiscretion.  Dietary  indiscretion:     (a)  over- 

feeding; (6)  decomposed;  (c) 
shellfish;  (</)  personal  idio- 
syncrasy. 

Vomiting    sudden,    forcible,    re-      Vomiting  distinctly  modified  by 
peated.  not  modified  by  treat-          treatment, 
ment. 

Symptoms  of  meningitis.  Meningism  only. 

Paralysis.  Xo  paralysis. 

Eclampsia. — The  onset  of  poliomyelitis  in  the  pregnant 
woman  closely  simulates  a  uremic  attack.  The  following 
valuable  account  of  a  case,  cited  by  Wickmann,  and  ab- 
stracted by  Frost,  is  given  in  preference  to  others  known, 
as  the  autopsy  findings  proved  the  presence  of  the  acute 
infection : — 


218  IX1-AXT1LE    PARALYSIS. 

II.  K.,  female,  aged  27  years,  married,  taken  sick  suddenly  Auj. 
19,  1905,  with  fever,  headache,  pains  in  back;  next  day  vomited 
so  suddenly  as  to  dislocate  the  jaw ;  tenderness  and  stiffness  of  neck, 
increasing  until  head  was  moderately  retracted ;  violent  tonic  con- 
traction of  the  shoulder  muscle,  throwing  the  arms  up  to  the  head : 
tonic  contractions,  flexing  elbows,  flexing  fingers,  and  adductmg 
thumb;  no  ocular  paralysi>;  cramps  so  painful  as  to  require  chloro- 
form; evening  temperature  99.6°  F.  Patient  fully  consciou- : 
opisthotonus.  August  21  st:  temperature  101.8°  F. ;  patient  being 
six  months  pregnant,  eclampsia  was  suspected  and  forced  delivery 
was  undertaken  successfully ;  cramps  continued,  extending  to  legs ; 
inability  to  swallow  and  difficulty  of  speech  developed  later  the 
same  day;  condition  continued  until  death  at  6  A.M..  August  22cl. 
Patient  conscious  throughout.  An  autopsy  was  performed,  reveal- 
ing typical  histologic  lesions  of  acute  poliomyelitis.  The  cerebro- 
spinal  fluid  was  found  greatly  increased  in  quantity  and  quite  clear. 

Here  again  poliomyelitis  has  shown  its  protean  charac- 
ter, by  closely  simulating  a  condition  and  disease  to  which 
it  is  unrelated.  The  points  of  differentiation  in  a  case 
of  uremic  convulsions  would  be  the  albumin-loaded  urine, 
possibly  diarrhea,  sudden  amaurosis,  and  uremic  coma. 
The  dyspnea  and  cyanosis  are  also  much  more  severe  in 
uremic  convulsions,  and  there  may  be  a  history  of  Bright's 
disease  of  the  kidney. 

Trichiniasis. — Trichiniasis  during  the  period  of  onset 
is  not  so  apt  to  be  confused  with  i>oliomyelitis  as  it  is  at  the 
time,  ten  days  later,  of  the  liberation  of  the  embryos  in  the 
invaded  muscles. 

A  poliomyositis  is  established :  the  muscles  become  in- 
tensely painful,  swollen,  and  hyperesthetic ;  an  involvement 
of  the  diaphragm,  which  is  usual,  causes  painful  and  im- 
peded respiration :  taken  with  the  history  of  the  attack  a 
few  days  away,  of  pain,  vomiting  and  fever,  a  picture 
is  left  on  the  mental  retina  which  may  be  closely  simulated 
by  the  onset  of  poliomyelitis. 


D1FFEREXTIAL    DIAGNOSIS.  219 

A  clear  history  .of  eating"  uncooked  pork  or  sausage 
must  be  obtained  before  the  diagnosis  can  be  made.  \}y 
Herrick's  method  the  Trichinclla  spiral  is  may  be  recovered 
from  the  circulating  blood. 

RacJiitis. — The  characteristic  rachitic  rosary,  the  bi- 
lateral asymmetry  of  the  paretic  legs,  and  the  negative 
electric  reactions  will  serve  to  distinguish  a  case  of  rickets 
from  the  suspicion  of  the  acute  infection. 

Tuberculosis  of  Joints  Jl'itJi  Pivation  from  Pain. — 
Professor  Eccles,  of  the  medical  department  of  Marquette 
L'niversity,  was  called  in  consultation  to  see  a  boy  of  id 
years,  with  a  supposed  tuberculosis  of  hip-joint  immobilized 
by  pain.  He  found  a  fourth-week  case  of  poliomyelitis, 
with  a  clear  history  of  acute  onset,  occurring  while  the 
disease  was  an  epidemic  in  the  State  of  Wisconsin. 

It  would  seem  that  the  characteristic  insidious  approach 
of  tuberculosis,  with  fever,  apathy,  and  emaciation,  would 
be  in  such  marked  contrast  to  the  acute  onset,  sudden 
paralysis,  and  rapid  atrophy  of  poliomyelitis  that  a  mis- 
take in  diagnosis  could  not  occur. 

The  affected  joint  in  tuberculosis,  in  addition  to  the 
pain  and  tenderness,  is  swollen  and  perceptibly  changed  in 
outline  from  its  fellow.  The  immobility  is  that  of  fixation 
m>m  pain  and  is  not  a  paralysis  or  paresis.  The  family 
history  may  be  positive,  complicated  with  deaths  from 
pneumonia  or  consumption. 

The  paralytic  limb  in  poliomyelitis  is  undergoing  re- 
generation, a  regression  of  the  paralysis,  or  rapid  atrophy. 
The  affected  muscles  show  the  reaction  of  degeneration, 
and  the  entire  history  is  one  of  an  acute  disease. 

A  case  of  poliomyelitis  affecting  the  left  glutei  and  ab- 
dominal muscles  strongly  resembling  tuberculous  coxitis 
is  given  by  Sheffield,  of  New  York: — 


220  1XFAXT1LE    PARALYSIS. 

J.  C.,  2.  years  old,  came  to  the  Babies'  Hospital  Dispensary 
(Dr.  H.  E.  Male's  division)  with  the  following  history:  Having 
been  perfectly  well  up  to  four  days  before,  he  suddenly  complained 
of  pain  in  the  legs  and  seemed  to  have  a  slight  rise  of  tempera- 
ture. The  family  physician  was  consulted,  but  finding  no  tangible 
cause  for  the  complaint  he  administered  a  laxative  and  ordered  to 
keep  the  child  in  bed  for  a  day  or  two.  The  next  day  the  patient 
was  out  of  bed,  but  off  and  on  continued  to  complain  of  pain,  espe- 
cially in  the  left  leg.  It  was  for  this  symptom  that  he  was  brought 
under  our  observation.  On  examination  I  found  that  he  was  able 
to  make  free  use  of  the  extremities  while  in  sitting  posture  and  also 
able  to  walk,  though  he  did  it  with  reluctance,  holding  the  leg  stiff. 
The  child's  musculature  as  a  whole  was  flabby  and  no  perceptible 
difference  could  be  elicited  between  the  muscles  of  the  different 
extremities.  As  pain  and  a  slight  limp  were  at  that  time  the  most 
characteristic  symptoms,  and  as  the  onset  and  course  of  the  attack 
were  so  exceptionally  brief,  it  required  quite  a  stretch  of  imagina- 
tion to  pronounce  the  case  as  poliomyelitis.  Indeed,  noting  also 
that  there  was  slight  asymmetry  between  the  gluteal  regions  (which 
later  proved  to  be  atrophy  of  left  gluteal  muscles),  and  on  further 
inquiry  having  learned  that  the  child  had  recently  sustained  a  fall, 
I  was  rather  inclined  to  the  belief  that  the  patient  might  be  suffer- 
ing from  incipient  coxitis.  I  could  not  help  thinking  also  of  rheu- 
matism, pain  being  the  predominating  factor.  However,  all  specu- 
lative theories  soon  went  to  naught.  On  the  second  visit,  one  week 
later,  I  found  the  left  gluteal  muscles  distinctly  atrophied  and  the 
abdominal  muscles  equally  affected.  Moreover,  a  few  days  later 
[.  R.,  a  little  girl  17  months  old,  living  in  the  same  flat  one  floor 
above,  was  brought  to  the  clinic  suffering  from  complete  paralysis 
of  the  left  leg  except  the  foot,  partial  paralysis  of  the  right  leg, 
and  unilateral  paralysis  of  the  abdominal  muscles.  This  child  had 
the  attack  of  poliomyelitis  about  two  weeks  before  the  aforemen- 
tioned boy,  her  playmate. 

"By  reason  of  their  superficial  resemblance  to  hip-dis- 
ease cases  of  the  above  ....  painful  type  form  a  group 
which  is  of  great  importance.  Pain,  wasting  of  the  but- 
tock muscles,  and  general  weakness  are  suggestive  symp- 
toms; and  when  to  these  are  added  a  tubercular  family 


DIFFERENTIAL    DIAGNOSIS.  221 

history,  the  combination  is  apt  to  prove  too  much  for  the 
unwary  practitioner,  who  forthwith  diagnosed  morbus 
coxae 

"While  many  authors  devote  considerable  space  to  the 
differential  diagnosis  of  morbus  cox;e  ///  so  far  as  it  may  be 
mistaken  for  infantile  paralysis,  not  one  of  those  I  am 
acquainted  with  mentions  the  possibility  of  the  converse 
error.  Yet  when  the  latter  mistake  is  made  the  conse- 
quences are  most  serious.  The  child  is  laid  up  for  weeks 
and  months  without  the  slightest  improvement,  and  I  have 
even  come  across  I  case  where  the  joint  was  opened  in  the 
confident  expectation  of  finding  a  tuberculous  focus." 
( Hernaman- Johnson,  "On  the  Occurrence  of  Pain  and 
Other  Sensory  Disturbances  in  the  Chronic  Stage  of  In- 
fantile Paralysis.") 

It  is  evident  that  \vhen  a  man  of  Trevelyan's  standing 
is  said  to  have  observed  acute  paralysis  following  imme- 
diately upon  such  different  infections  as  measles,  typhoid 
fever,  and  acute  rheumatic  fever,  having  obviously  been 
unacquainted  with  the  characteristic  measly  rash  and  not 
infrequent  appearance  of  a  typhoid  condition  and  myalgia 
in  acute  poliomyelitis,  the  family  physician  must  constantly 
have  in  mind  the  possibility  of  any  illness  with  acute  onset 
developing  into  this  disease.  The  most  striking  example 
of  mistaken  diagnosis  we  have  met  with  in  literature  is 
given  by  Dr.  Lovett,  in  the  account  of  the  cases  in  the  1909 
Massachusetts  epidemic,  as  follows:— 

Intussusception  of  Bowel. — D.  G.,  2l/2  years  old;  August  8th, 
onset  fever,  rigidity  of  spine,  retraction  of  head ;  vomited ;  reten- 
tion of  urine  fourth  day;  fifth  day  removal  to  hospital  and  operated 
for  supposed  intussusception  of  bowel.  Nothing  was  found  except 
an  excessively  distended  bladder;  on  August  i8th  appeared  paral- 
ysis of  both  legs  and  right  arm,  thus  establishing  diagnosis. 

Sunstroke  and  Heat  Prostration. — A  not  uncommon  mistaken 
diagnosis.  Presence  of  epidemic  should  be  considered. 


222  INFAXT1LE    PARALYSIS. 

Cerebral  Hemorrhage. — The  prodromal  symptoms  of  polio- 
myelitis and  the  fact  that  there  is  seldom  any  disorientation  of  time 
or  place  in  poliomyelitis  are  sufficient  diagnostic  points. 

Sprained  Ankle.  Dislocation  of  the  Shoulder-joint. — Acute 
poliomyelitis  with  paralysis  of  the  legs  in  a  4-year-old  boy  diagnosed 
sprained  ankle,  reported  by  Peabody  and  Draper.  Dislocation  of 
the  shoulder-joint  not  infrequently  mistaken  diagnosis.  Ager,  of 
Brooklyn,  called  as  consultant  to  the  case  of  a  2-year-old  girl,  was 
told  that  the  child  had  forgotten  how  to  walk. 


CHAPTER    IX. 

Prognosis  in  Acute  Epidemic  Poliomyelitis 
as  to  Life  and  Disability. 

A  GUARDED  prognosis  should  always  be  given  in  polio- 
myelitis. The  prognosis  is  grave  while  the  disease  is 
progressing  and  the  paralysis  advancing.  The  motor 
symptoms  of  the  preparalytic  stage  are:  tremor,  twitching 
of  muscles,  jerking  of  limbs,  and  spasticity.  The  paralysis 
of  the  diaphragm  is  usually  last ;  when  a  patient  develops 
abdominal  breathing,  and  chest  muscles  are  fixed  or  im- 
movable, give  a  fatal  prognosis,  no  matter  how  favorable 
other  conditions  may  look:— 

MORTALITY  RATE  IX  SIX  EPIDEMICS  OF  POLIOMYELITIS. 

Reported  Mortality 

by  Locality.  Year.        Total  cases.  Deaths.       rate. 

Harbitz  Per  cent- 

and  Scheel.  .Norway  1905-6  1053  145  13.8 

\\ickmann Sweden  1905-6  1025  159  15.0 

Hill Minnesota  1909  283  68  24.0 

Lovett Massachusetts  1909  628  51  8.1 

Frost X.  Y.  State  1910  227  34  15.0 

Bierring Iowa  1910-11  722  169  23.4 


Totals 3938          626  1 5.9 

The  immediate  cause  of  death  in  poliomyelitis  is  paral- 
ysis of  respiration,  meningitis,  or  toxemia,  but  a  con- 
tributing cause  appears  to  be  strenuous  exercise  taken  after 
the  onset  of  the  disease.  Ball,  in  reporting  St.  Paul  cases, 
remarked  that  in  the  fatal  cases  the  patients  had  taken  a 
varying  degree  of  exercise  after  onset.  Spiller,  in  report- 

(223) 


224  IX  FA  XT  ILK    PARALYSIS. 

ing  a  case  of  poliomyelitis  in  an  adult  who  walked  8  miles 
after  onset,  questions  if  the  disease  might  not  have  re- 
mained in  the  abortive  (arrested)  form,  if  this  exertion 
had  been  avoided  at  onset.  (Spiller,  "Diagnosis  of  Polio- 
myelitis," Penn.  Med.  Jour.,  December,  1911.) 

The  mortality  rate  of  15  per  cent,  for  all  cases  rises 
to  25  per  cent,  for  children  less  than  I  year  of  age.  for 
adolescents  and  for  adults.  Males,  being  vastly  more 
liable  to  the  infection  than  females  (Caverly,  "Acute  Ant. 
Poliomyelitis  in  Vermont,"  Jour.  Amer.  Med.  Assoc., 
January  4,  1896),  show  a  correspondingly  greater  death 
percentage. 

The  stricter  the  investigation  of  cases,  the  higher  the 
mortality  record  has  proved;  thus  Hill,  discarding  every 
case  not  presenting  an  actual  paralysis  from  his  record 
given  above,  found  68  deaths  among  283  cases  in  Minne- 
sota in  1909,  a  mortality  rate  of  24  per  cent.  We  must 
remember  that  the  inclusion  of  arrested  cases  would  greatly 
modify  this  fatality  rate. 

The  mortality  rate  varies  in  wide  degree  in  local  out- 
breaks ;  Harbitz  noted  this  in  speaking  of  one  Norwegian 
district  where  26  cases  occurred  with  12  deaths,  a  fatality 
rate  of  48  per  cent.  This  fluctuation  was  shown  in  two 
small  outbreaks  at  seaside  resorts  in  this  country:  the  first 
one  was  cited  by  Morse  (Boston  Med.  and  Surg.  Jour., 
January  12,  1911).  There  were  8  children  of  about  the 
same  age  in  a  small  summer  colony  at  the  shore.  All  of 
them  had  an  acute  gastrointestinal  disturbance  with  slight 
fever  lasting  from  four  to  five  days.  One  of  them  was 
found  a  \veek  later  to  have  a  slight  paralysis  of  both  legs 
and  one  arm.  It  is  fair  to  assume  the  others  had  poliomye- 
litis also  in  an  abortive  (arrested)  form.  A  doctor's  only 
son,  and  a  girl  playmate,  died  during  the  acute  stage ;  there 
were  no  other  cases. 


PROGNOSIS    IX   ACUTE    EPIDEMIC    POLIOMYELITIS.        225 

The  mortality  rate  also  varies  according  to  age,  sex, 
area,  and  extent  of  cord  involvement,  and,  as  observed 
by  Shidler,  the  time  of  the  epidemic  in  which  the  case 
occurs.  Shidler  noted  in  the  York,  Nebraska,  epidemic 
that  the  last  cases  had  a  higher  degree  of  fatality;  this 
may  be  due  to  a  direct  enhancement  of  the  virulence  of  the 
infection  with  the  advancing  plague;  it  was  seen  to  occur 
in  the  artificial  propagation  of  the  disease.  The  prognosis 
as  to  life  is  more  favorable  between  the  ages  of  i  and  10 
years  than  in  infancy,  adolescence,  or  adult  life.  Adult 
males  seem  to  have  not  more  than  one  chance  in  two  of 
surviving  the  attack. 

HIGHER  MORTALITY  IX  THE  MORE  ADVAXCED  AGES. 

Reported  by  Age.  Per  cent. 

\\ickmann,   Sweden    12  to  32  years.  27.6 

Leegaard,   Norway    15  to  30  years.  25.8 

Fiirntratt,  Steiennark   . Over  15  years.  25.5 

Lindner  and  Mally.  Austria Over  1 1  years.  50.0 

Massachusetts.  U.  S.  A.,  1910 Over  10  years.  20.0 

(Lovett  and  Richardson.) 

Of  722  cases  reported  in  the  State  of  Iowa  in  1910-11 
<  nierring),  there  were  no  cases  over  15  years  of  age. 
The  mortality  rate  for  all,  23.4  per  cent.,  is  very  high. 

Prognosis  as  to  life  is  also  affected  by  the  segment  of 
the  cord  which  is  involved,  and  the  extent  of  the  involve- 
ment. The  higher  the  lesion  the  more  danger  of  the 
involvement  of  the  muscles  of  respiration,  or  the  vital 
centers.  Prognosis  is  also  grave  in  direct  ratio  with  the 
extent  of  cord  involvement.  In  New  York  State  in  1910 
there  were  55  cases  of  paralysis  of  one  leg  only  and  no 
deaths  in  that  series,  while,  of  30  cases  which  presented 
paralysis  of  all  four  extremities,  only  12  remained  alive; 
1 8  of  the  cases,  or  60  per  cent,  of  the  number,  died. 


226  1XFAXTILE    PARALYSIS. 

In  fatal  cases  there  is  usually  no  decline  in  temperature 
with  the  onset  of  the  paralysis. 

If  the  case  survives  the  eighth  day  the  prognosis  is 
hopeful.  About  12  per  cent,  of  all  cases  die  during  the 
acute  stage,  or,  to  state  it  somewhat  differently,  80  per  cent, 
of  all  fatal  cases  die  in  the  first  week  of  the  disease. 

Sporadic  Cases. — It  has  been  stated  by  several  authori- 
ties that  the  mortality  rate  is  much  lower  in  sporadic  cases ; 
no  evidence  having  been  brought  forward,  the  optimistic 
hazard  remains  unproven.  If  by  sporadic  it  is  intended 
to  designate  cases  which  occur  singly  with  no  known 
relationship  to  other  cases  of  poliomyelitis,  whether  such 
relationship  has  been  intelligently  sought  or  not,  it  is  doubt- 
less true  that  proper  investigation  would  uncover  such 
relationship,  and  perhaps  discover  the  cause  of  many 
mysterious  and  obscure  deaths.  It  is  evident  that  we  must 
gather  much  more  information  about  the  so-called  sporadic 
form  of  poliomyelitis  before  we  can  more  than  hazard  its 
mortality  rate. 

Paralysis,  Impending,  Progressive,  and  Regressive.— 
The  motor  symptoms  of  the  preparalytic  stage  of  poliomye- 
litis are:  tremor,  twitching  of  muscles,  jerking  of  limbs, 
and  spasticity.  During  the  onset  of  a  case  of  poliomyelitis 
it  is  now  possible  to  prognosticate,  by  lumbar  puncture  and 
the  examination  of  the  spinal  fluid,  whether  the  illness  will 
eventuate  in  paralysis.  This  method  was  carried  to  bril- 
liant execution  by  Drs.  Frizzell  and  Flexner  in  the  case 
of  a  Princeton  student  in  1910.  By  the  use  of  this  method 
the  diagnosis  was  established,  and  the  probable  appearance 
of  the  paralysis  determined  twenty-four  hours  before  onset ; 
a  second  puncture  twenty-four  hours  after  onset  of  paral- 
ysis demonstrated  the  height  of  the  paralysis  passed,  and 
the  paralytic  stage  terminating. 

During  the  acute  stage  of  poliomyelitis  the  spinal  fluid 


PROGNOSIS    IN    ACUTE    EPIDEMIC    POLIOMYELITIS.         227 

increases  in  volume;  this  is  shown  by  increased  pressure 
when  the  spinal  canal  is  tapped,  for  the  fluid  drops  rapidly 
from  the  needle  or  may  spurt  with  a  force  which  projects 
the  stream  several  inches.  Any  acceleration  of  the  normal 
slow  drop  flow  indicates  plus  pressure.  In  poliomyelitis 


Fig.  66. — Scoliosis  following  acute 
poliomyelitis.  (N.  Y.  Hospital  for 
Deformities  and  Joint  Diseases.) 


Fig.  67. — Scoliosis  following  poli- 
omyelitis. (N.  Y.  Hospital  for 
Deformities  and  Joint  Diseases.) 


the  spinal  fluid  is  clear  during  the  onset  of  the  disease, 
becomes  slightly  opalescent  in  the  preparalytic  stage,  and 
again  clears  as  the  height  of  the  paralytic  stage  is  reached. 
This  method  is  the  most  valuable  aid  which  we  possess  in 
the  prognosis  of  both  the  progressive  and  regressive  stages. 


228  IXFAXTILE    PARALYSIS. 

lirorstrom,  of  Sweden,  collected  394  cases  of  poliomye- 
litis (  1905-6),  of  which  only  79  showed  a  paralysis  of  any 
degree. 

Spontaneous  recovery  frequently  occurs  in  mild  ca^e-. 
and  ensues  in  about  16  per  cent,  of  paralytic  cases.  In  the 
Massachusetts  epidemic  of  1909,  25  of  150  paralytic  cases 
made  an  absolutely  complete  recovery.  These  cases  were 
investigated  with  the  utmost  thoroughness,  and  the  re- 
covery cases  were  examined  ;  they  were  stripped  naked  and 
the  separate  movements  c\f  ankle,  knee,  hip,  spine,  abdomen, 
and  arms  were  separately  tested;  they  were  found  to  have 
made  a  complete  recovery.  \\'e  are  indebted  to  Dr.  Robert 
Lovett,  of  the  Massachusetts  State  Board  of  Health,  for 
this  very  reassuring  analysis.  (  Bull.  Mass.  State  Board 
of  Health,  June,  1910.) 

EXTENT  OF  PARALYSIS  IX  25  CASES  OF  POLIOMYELITIS  WHICH 
SUBSEQUEXTLY  MADE  COMPLETE  RECOVERY.     (LOVETT.) 

One  thigh  and  one  leg  ......  .  ...................  4 

Both  thighs  and  both  legs  .......................  8 

I?oth  thighs  ...................................  r 

One  leg  ......................................  2 

One  arm  .....................................  i 

One  arm,  back,  and  one  leg  .....................  i 

One  leg  and  back  ..............................  i 

One  thigh,  leg.  arm  and  forearm  ................  i 

One  arm  and  forearm  and  cervical  region  .........  i 

Cervical  region  ................................  4 

Indefinite  staggering  gait  (ataxic  type  )  ..........  i 


These  recovered  cases  were  in  no  way  distinguished 
from  other  cases  by  the  character  of  onset,  distribution  of 
paralysis,  or  tenderness;  the  paralysis  lasted  from  three 
days  to  twelve  weeks;  the  cases  ranged  in  age  from  i  to  21 
years.  The  cases  all  suffered  from  frank  paralysis  save 


PROGNOSIS    JX    ACUTE    EPIDEMIC    POLIOMYELITIS.         229 

i.  which  was  of  the  ataxic  type.  The  possibility  of  such  a 
complete  recovery  is  very  reassuring  to  the'  parents,  al- 
though a  prognosis  in  this  disease  must  at  all  times  be 
guarded. 

Although  the  symptoms  of  onset  are  not  dependable  in 
prognostication,  it  has  been  frequently  observed  that  cases 
which  begin  with  a  diarrhea  are  usually  mild  in  type,  and 
the  paralysis  usually  transitory ;  while  cases  presenting  the 
profound  constipation  are  more  serious  in  degree.  \Yhen 
the  decline  in  temperature  precedes  the  paralysis  more 
than  forty-eight  hours,  the  paralysis  is  usually  of  a  mild 
type. 

DISTRIBUTION  OF  PARALYSIS. 

Mass.,  1909  New  York  State, 
(Lovett).       1910  (Frost). 

One  leg  only   192  55 

Both  legs  only   151  65 

One  arm  only   32  16 

Both  arms  only 1 1  8 

Arm  and  leg   74  28 

Both  legs  and  one  arm 38  12 

One  leg  and  both  arms   6  2 

Both  legs  and  both  arms  82  30 

Hack    83  34 

Abdomen   37  20 

Face    34  13 


740  283 

Residual  Paralysis. — Spontaneous  recovery  from  the 
paralysis  may  be  rapid  for  several  weeks,  when  no  farther 
advance  is  observed.  The  complete  recovery  of  one  ex- 
tremity, while  its  fellow  is  left  with  a  serious  residual  palsy, 
is  most  often  seen.  The  percentage  of  cases  left  with  a 
residual  palsy  has  been  variously  estimated.  In  an  editorial 
in  Pediatrics  (August,  1910),  it  is  given  as  80  per  cent. 
This  estimate  is  somewhat  higher  than  was  found  by  Hill 


230 


INFANTILE    PARALYSIS. 


in  his  study  of  283  paralytic  cases.  Of  the  283,  a  good 
recovery  was  made  by  15  per  cent.,  while  24  per  cent.  died. 
There  remained  then  60  per  cent,  more -or  less  crippled  by 
the  attack;  but  as  Hill  in  this  study  excluded  all  cases  of 
the  arrested,  ataxic,  neuritic,  or  meningitic  type  which  did 
not  show  a  distinct  paralysis,  it  becomes  evident  the  in- 


Fig.  68. — Paralysis,  atrophy,  contractures  and  deformity  eighteen 
months  after  attack  of  poliomyelitis,  in  a  girl  11  years  of  age.  (  X.  Y. 
Hospital  for  Deformities  and  Joint  Diseases.) 

elusion  of  such  cases  would  have  lowered  the  percentage 
of  cases  of  persistent  paralysis  and  atrophy  to  somewhat 
below  60. 

Cortical  involvement  may  occasion  convulsions,  hemi- 
plegia,  mental  deficiency,  and  epilepsy.  The  mental  defi- 
ciency may  be  any  one  of  the  three  grades :  Idiots,  those 
children  who  never  develop  beyond  the  mental  age  of  3 


PROGNOSIS    IX    ACUTE    EPIDEMIC    POLIOMYELITIS. 


231 


years;  imbeciles,  individuals  retarded  mentally  to  the  age 
of  7  years;  morons,  those  high-grade  fools  that  remain  at 
the  mental  age  of  12  years. 


Fig.  69. — Posterior  view  of  Fig.  68.          Fig.   70. — Lateral   view   of  Fig.   68. 

ARREST  OF  GROWTH  OF  LONG  BONES  AND 
AMOUNT  OF  SHORTENING. 

Arrest  of  growth  is  proportionate  to  growth  rate,  and 
the  younger  the  child  affected  the  greater  the  possible 
.shortening.  The  degree  of  shortening  usually  bears  some 
proportion  to  the  degree  of  severity  of  the  paralysis,  but 
this  is  not  constant  and  not  at  all  dependable  for  prognostic 
purposes.  An  extremity  with  a  light  paralytic  attack 
which  occurred  in  early  infancy  may  have  almost  unim- 
paired function  and  yet  present  a  shortening  of  four  or 
more  inches.  In  an  extremity  with  an  extensive  flaccid 


232  IX  KAN  TILE    PARALYSIS. 

paralysis  there  may  be  an  actual  shortening  of  less  than  an 
inch,  and  very  occasionally  cases  have  been  noted  of  actual 
lengthening.  Trophic  disturbance  of  bone  development  is 
usually  associated  directly  with  muscle  involvement,  as  the 
tibia  and  fibula  are  most  apt  to  show  shortening  when  the 
muscles  below  the  .knee  are  paralyzed,  while  the  involve- 
ment of  the  muscles  of  the  thigh  usually  accompanies 
shortening  of  the  femur. 

ATROPHY;  HYPERTROPHY;  TIME  OF 
RECOVERY. 

In  Wood's  study  of  57  cases  reported  recovered  in  the 
Massachusetts  epidemic  of  234  cases  in  1907,  it  was  found 
that  there  were  three  classes  of  recovery:  (i  )  complete 
recovery  without  atrophy;  (2)  recovery  with  complete 
function,  but  with  some  atrophy:  (3)  recovery  with  SOUK- 
hypertrophy  of  the  affected  limbs. 

The  table  shows  the  proportion  of  each  of  these.:— 

Per  cent. 

Complete  recovery  without  atrophy K>         28.1 

Functional  recovery  with  atrophy 21          ^o.S 

Recovery  with  some  hypertrophy ^  5. ; 

Recovery,  presence  or  absence  of  atrophy  unknown .  .    17         29.8 

(  \YootU 

Leaving  out  the  last  group,  and  averaging  those  in 
which  the  presence  or  absence  of  atrophy  is  known,  shows 
that  for  every  4  recoveries  without  atrophy  there  were  5 
with  atrophy.     \Yhen  atrophy  was  present  the  maximum- 
amount  noted  was  as  follows : — 

Inches. 
Calf    i# 

Thigh iy4 

Arm 

Forearm    4 


PROGNOSIS    IN    ACUTE    EPIDEMIC    POLIOMYELITIS.         233 

in  most  cases  the  atrophy  was  much  less  than  this,  a 
difference  of  one-eighth  of  an  inch  being  counted  as 
atrophy,  but  in  all  such  cases  examined  function  of  every 
muscle  was  perfect.  Three  cases  had  only  one-eighth  inch 
atrophy  of  one  limb;  2  cases  only  one-fourth  inch  of  one 
limb;  5  cases  only  one-eighth  inch  of  one  limb  and  one- 
fourth  inch  of  another ;  the  other  1 1  cases  had  more  than 
one-fourth  inch  atrophy.  The  amounts  of  hypertrophy 
recorded  were  in  2  instances  one-fourth  inch  and  in  I 
three-eighths  inch,  all  of  the  calf. 

TIME  OF  RECOVERY- 

Cases. 

i  week  or  less 2 

i   \veek  to  i  month   8 

1  to  2  months   8 

2  to  3  months   : 5 

3  months  to  6  months   10 

6  months  to  12  months   9 

1  to  2  years .      5 

2  to  3  years   5 

X<>  data    5 

Total    •. 57 

(Wood.) 

To  illustrate  late  recovery,  and  recovery  from  severe 
attack,  _'  cases  were  especially  notable:— 

YV.  1 1.  and  J.  H.,  brothers,  aged  n  and  13,  patients  of  Dr.  J.  C. 
Ilubbard,  of  Holyoke,  were  attacked  Oct.  12  and  13,  1907,  re- 
spectively. 

The  duration  of  the  acute  attack  was  three  weeks  in  each  case, 
that  of  W.  H.  being  moderate  and  that  of  J.  H.  severe.  The  latter 
had  a  temperature  of  103°  F.  for  a  week,  vomiting  for  several  days 
and  severe  coma  for  two  weeks,  with  marked  retraction  of  head. 
The  distribution  of  his  paralysis  at  its  worst  was  both  thighs,  left 
leg,  left  arm  and  left  forearm,  and  lower  back.  The  arm  and  back 
recovered  in  one  month. 


234  IX  FAX  TILE    PARALYSIS. 

The  distribution  of  \V.  H.'s  paralysis  was  left  thigh  and  left 
leg. 

The  treatment  was  the  same  in  both  cases  and  consisted  of 
massage  and  tabetic  exercises  begun  in  November,  1907,  after  the 
acute  onset. 

I'.oth  patients  were  in  bed  three  weeks  and  had  to  be  carried 
for  two  months  and  then  walked  with  a  limp,  the  lameness  being 
very  marked  in  the  case  of  J.  H.  during  the  first  year.  Massage 
was  given  every  night  for  two  years.  The  greatest  gain  occurred 
during  the  second  year  and  practical  recovery  occurred  during  the 
third  year. 

An  examination  in  May,  1911,  showed  no  paralysis  in  either 
case.  W.  H.  had  one-eighth  inch  atrophy  of  left  calf  and  one-half 
inch  of  left  thigh.  J.  H.  had  one-eighth  inch  atrophy  of  right  calf 
and  no  atrophy  of  the  thigh  or  arm. 

The  following  conclusions  seem  justified  :— 
In  anterior  poliomyelitis  complete  recovery  or  func- 
tional recovery  occurs  in  something  over  25  per  cent,  of 
cases  examined  at  the  end  of  four  years.  Atrophy  may 
exist  without  impairment  of  function.  In  about  half  of 
the  recovered  cases,  the  onset  was  mild.  The  distribution 
of  the  paralysis  in  such  recovered  cases  was  not  essentially 
different  from  that  in  cases  which  do  not  recover.  Re- 
covery in  many  instances  required  months,  and  in  several 
cases  from  one  to  three  years.  (Wood,  Bulletin  Massa- 
chusetts State  Board  of  Health,  1912.) 

SUMMARY. 

A.  The  motor  symptoms  of  the  preparalytic  stage  of 
poliomyelitis  are  :— 

.  Tremor. 

Twitching  of  muscles. 
Jerking  of  limbs. 
Spasticity. 


PROGNOSIS    IX    ACUTE    EPIDEMIC    POLIOMYELITIS.         235 

B.  Lumbar  puncture  and  examination  of  spinal  fluid 
may  determine  :— 

Paralysis   (a)   impending. 
.  (b)   progressive, 
(c)   regressive. 

C.  The  prognosis  of  poliomyelitis  is  hopeful  -when:— 

i.  The  patient  is  more  than  I  and  less  than  10  years  of  age. 
_'.   With  mild  onset   (not  dependable"). 

3.  With  diarrhea  at  onset. 

4.  With  decline  of  fever  by  crisis  preceding  paralysis. 

5.  When  decline  of  fever  precedes  onset  of  paralysis  by  more 

than  forty-eight  hours,  usually  very  mild  type. 

6.  With  paralysis  of  one  lower  extremity. 

7.  When  paralysis  is  regressive  in  type. 

8.  If  patient  survives  eighth  day. 

9.  With  absolute  rest  in  bed  from  onset. 

/>.  The  prognosis  in  poliomyelitis  is  grave  when:— 

1.  The  patient  is  less  than   i   year  of  age,  an  adolescent,  or 

an  adult. 

2.  When  onset  is  characterized  by  severe  symptoms  (not  de- 

pendable). 

3.  With  suppressed  eliminations. 

4.  With  strenuous  exercise  or  exposure  to  heat  after  onset. 

5.  With  no  decline  in  temperature  as  paralysis  supervenes. 

6.  While  paralysis  is  advancing. 

/.  With  paralysis  of  all  extremities. 

8.  With  paralysis  of  upper  segments. 

9.  With  paralysis  of   diaphragm,  intercostals.  or  muscles  of 

pharynx. 

10.  Character  of  epidemic  (virulent). 

11.  Time  in  epidemic  (late). 


CHAPTER    X. 

Prophylaxis  of  and  Immunity  from 
Poliomyelitis. 

COMMUNAL;   INDIVIDUAL;   PHYSICIAN. 

THE  experimental  transmission  of  acute  poliomyelitis 
has  been  effected  only  by  inoculation,  by  (a)  the  injection 
of  a  healthy  animal  with  poliomyelitic  tissues;  (b]  the  bite 
of  biting  stable-flies  previously  allowed  to  feed  on  polio- 
myelitic  animals;  (r)  the  injection  of  healthy  animals  with 
the  comminuted  bodies  of  bedbugs  previously  fed  on  polio- 
myelitic animals.  The  spontaneous  transmission  of  acute 
poliomyelitis  has  been  known  to  occur  from  inoculation  of 
man  by  a  paralytic  dog.  (Langhorst.) 

There  is  no  proof  that  spontaneous  transmission  of 
acute  poliomyelitis,  without  an  inoculation  wound,  can  take 
place.  There  is  no  proof  that  contact  contagion  takes 
place.  Spontaneous  development  of  the  disease  among 
laboratory  animals  is  unknown.  The  toxic  buccal  secre- 
tions (saliva)  of  a  case  induce  the  disease  only  when  in- 
jected into  the  healthy  animal  through  an  inoculation 
wound.  Fomites,  said  to  carry  contagion,  have  been  shown 
infective  only  by  injecting  water  in  which  they  were  laved 
into  an  inoculation  wound. 

COMMUNAL    PROPHYLAXIS. 

In  view  of  the  foregoing,  rational  communal  prophy- 
laxis against  epidemic  poliomyelitis  must  be  wider  in  scope 
than  the  hitherto  tenuous  advice  to  secure  street  sprinkling 
for  the  city,  and  nasal  antisepsis  for  the  citizen.    Adequate 
(236) 


IMMUNITY    FROM    POLIOMYELITIS.  237 

measures  must  be  taken  to  secure  the  citizens  immunity 
from  transmission  of  the  disease  from 
(  i  )   the  human  case ; 

( 2 )  the    paralytic    animal,    dog,    horse,    hog,    sheep, 

rabbit,  pigeon,  barnyard  fowl,  cat; 

(3)  blood-sucking  insect,  parasite  of  animal  and  man, 

(a)  the  biting  stable-fly,  Stomo.vys  calcitrant; 

(b)  the  bedbug.  Ciinc.v  Icctnlarius; 

(c}  all  other  blood-sucking  insects :  mosquito, 
louse,  flea,  tick,  buffalo  gnat,  midge. 
sand-fly,  and  the  itch  ; 

( 4 )  contact  contagion  from  common  carriers,  such  as 

roller  towel,  public  drinking-cup,  etc.  (until 
theory  of  contact  contagion  is  absolutely  proven 
or  disallowed). 

In  addition  it  is  advisable  for  each  community  to  ap- 
point a  special  physician,  salaried,  as  advisory  consultant, 
epidemiologist,  and  delegate  to  an  international  clearing 
house  which  will  give  warning  of  the  approach  of  the 
epidemic  disease,  with  a  special  council  to  take  measures 
to  check  its  advance. 

1.  THE  HUMAN  CASE  AND   COMMUNAL  PROPHYLAXIS. 

A  legal  statute  making  epidemic  poliomyelitis  a  disease 
subject  to  public  control  is  the  first  requirement  in  com- 
munal prophylaxis.  The  London  Board  of  Health  re- 
quires notification  of  this  disease  with  a  fine  of  $10  for 
every  failure  to  report  a  case.  It  is  doubtless  true  that 
such  a  law  and  such  a  forfeit  for  failure  to  comply  with 
the  law,  if  enforced,  would  bring  knowledge  of  thousands 
of  unreported  cases  occurring  each  season  in  the  various 
States,  each  unrecognized  case  a  communal  menace.  The 
enforcement  of  the  fine  might  result  in  more  careful  diag- 
noses. Poliomyelitis  was,  until  recently,  not  a  reportable 


938  IXFAXTILE    PARALYSIS. 

disease  in  the  State  of  Missouri;  a  communication  from 
Dr.  B.  S.  Yeecler,  of  the  Children's  Hospital  of  \Yashing- 
ton  University,  St.  Louis,  during  the  fall  of  1912,  states 
that  the  writer  is  not  sure  that  an  ordinance  making  polio- 
myelitis reportable  would  be  effective,  "as  cases  come  into 
the  hospital  under  the  diagnoses  of  rheumatism,  neuritis, 
and  diphtheria  of  the  stomach''  ( !  ).  The  strict  enforce- 
ment of  the  law  requiring  that  each  case  be  reported  to  the 
proper  authorities  has,  in  Sweden,  brought  the  exact 
knowledge  of  3800  cases  occurring  in  the  summer  of  1911, 
and  i<Soo  cases  up  to  August,  1912 ;  so  that  the  government 
at  least  knows  what  it  is  up  against  and  can  take  measures 
accordingly. 

A.  Classification  of  poliomyelitis  with  epidemic  diseases  under 
public  control. 

B.  Enforcement  of  notification  by  penalty  of  at  least  $10. 

C.  Report   to  include   precis   of   case,    with    environment    ami 
probable  source  of  infection. 

D.  Isolation  of  case  for  four  weeks  from  human  companion- 
ship, save  that  of  necessary  attendants. 

E.  Isolation  of  case  from  all  blood-sucking  insect.-:  absolutely 
maintained  by  screening,  and  partial  fumigation. 

F.  No  domestic  pets  permitted  in  or  about  chamber. 

G.  Disinfection  of  all  dishes,  linen,  secretions,  and  excretion- 
be  fore  removal  from  sick  chamber. 

H.  Quarantine  of  all  who  were  in  close  association  with  case 
for  a  period  of  ten  days  preceding  onset  of  disease,  such  quarantine 
to  be  maintained  for  ten  days. 

I.  Isolation  of  all  cases  developing  a  coincidental  febrile  con- 
dition, malaise,  cervical  rigidity,  or  motor  weakness,  for  a  period 
of  four  weeks,  the  same  precautions  regarding  blood-sucking  insects 
to  be  enforced. 

J.  Placarding  of  house  with  the  name  of  the  disease  given 
plainly. 

K.  Members  of  family  excluded  from  school.  I '.read  winners 
to  take  their  meals  elsewhere  and  use  separate  toilets  until  after 
final  fumigation. 


IMMUNITY    FROM    POLIOMYELITIS.  239 

L.  Final  fumigation  of  premises  with  sulphur  gas  under  pres- 
sure or  an  equally  valuable  method.  Formaldehyde  fumigation  for 
bedbugs  was  pronounced  worthless  by  Verjbitski  after  a  complete 
investigation. 

COMMUNAL  PROPHYLAXIS  AND  THE 
LOCAL  HEALTH  BOARD. 

During  the  Springfield,  Mass.,  epidemic  of  1911,  the 
following  were  used  by  the  -Springfield  Board  of  Health,  a 
copy  of  the  circular  sent  to  doctors  being  given  below: — 

HEALTH  DKI'ARTMKNT,  SI'KIXC.FIKLD,  MASS. 
ANTERIOR  POLIOMYELITIS. 

The  State  Board  of  Health  has  declared  anterior  poliomyelitis 
to  be  a  disease  dangerous  to  the  public  health,  and  as  such  must  be 
immediately  reported  to  the  local  board  of  health.  Failure 'to  comply 
with  this  statute  involves  liability  to  a  fine  of  $50  for  each  offence. 

From  all  information  obtainable  of  epidemics  of  this  disease  in 
other  places,  as  well  as  a  study  of  the  epidemic  now  in  progress 
in  this  city,  the  disease  is  without  doubt  of  an  infectious  and  con- 
tagious nature.  The  causative  agent  is  not  known,  but  the  mortality 
and  subsequent  paralyses  and  deformities,  which  are  only  too  much 
in  evidence,  place  anterior  poliomyelitis  amongst  the  diseases  most 
dangerous  to  life  and  future  usefulness. 

The  board  of  health  has  therefore  established  a  strict  isolation 
period  for  this  disease  of  four  weeks  from  date  of  notification,  with 
disinfection  at  termination  of  the  period.  No  public  funerals  will 
be  allowed  of  patients  dying  from  this  disease. 

It  is  only,  however,  through  the  earnest  and  active  co-operation 
of  the  medical  profession,  who  come  in  personal  contact  with  the 
disease,  that  definite  results  can  be  obtained  by  the  board  of  health 
in  checking  the  spread  of  the  epidemic. 

Physicians  are,  therefore,  urged  to  use  every  precaution  in 
preventing  its  spread  which  is  now  in  use  in  the  management  of 
other  contagious  diseases,  and  to.  explain  very  carefully  to  the 
family  the  dangers  arising  not  only  to  themselves,  but  to  others, 
from  a  disregard  of  the  regulations  of  the  board  of  health.  If  this 
line  of  action  is  pursued  by  the  medical  profession,  it  is  believed 


240  1XFAXTILE    PARALYSIS. 

that  as  good  results  will  be  obtained  as  to  undertake  the  establish- 
ment of  an  absolute  quarantine,  with  all  its  discomforts,  hardships, 
and  consequent  tendency  on  the  part  of  the  public  to  conceal  the 
existence  of  the  disease. 

If  physicians  will  advise  all  their  families,  as  a  matter  of  self- 
protection,  to  at  once  establish  a  voluntary  isolation  for  themselves. 
the  best  quarantine  possible  will  then  be  produced.  Children  should 
be  kept  at  home  and  not  allowed  to  attend  picnics,  excursions.  Sunday 
school,  theaters,  playgrounds  or  other  places  where  children  come 
together  in  numbers. 

July  27,  1910. 

HEALTH  DEPARTMENT.  SPRINGFIELD,  MASS. 
ANTERIOR  POLIOMYELITIS   (  INFANTILE  PARALYSIS). 

This  disease  is  contagious,  and  is  followed  in  a  great  many  case- 
by  paralysis  of  arms,  legs,  or  other  parts  of  the  body.  Deformities 
with  inability  to  use  the  arm  or  leg  are  liable  to  be  permanent. 

It  attacks  young  children  chiefly,  but  adults  are  by  no  means 
exempt.  It  is  therefore  of  the  utmost  importance  that  you  use  every 
means  possible  in  preventing  other  children  from  contracting  this 
disease. 

Xo  one  will  be  allowed  to  see  the  patient  except  the  necessary 
attendants  and  the  physician.  The  patient  must  be  cared  for  in  a 
room  isolated  from  the  other  members  of  the  family  during  the 
entire  period  of  isolation.  Mild  cases  which  are  only  sick  for  a  few 
days,  and  do  not  show  any  definite  paralysis,  are  just  as  liable  to 
convey  the  infection  as  the  more  serious  cases,  and  must  be  isolated 
for  the  full  period.  Every  case  should  remain  under  the  care  <>f 
your  physician  during  the  entire  isolation  period,  which  is  four 
weeks  from  the  date  of  notification  sent  to  the  board  of  health. 
Disinfection  will  then  follow  and  the  card  be  removed. 

If  the  regulations  of  the  board  of  health  are  not  observed  and 
the  patient  for  any  reason  is  not  or  can  not  be  properly  isolated,  the 
board  may  cause  such  patient  to  be  removed  to  the  isolation  hospital. 
The  importance  of  obeying  these  instructions  cannot  be  overesti- 
mated, as  a  large  percentage  of  children  who  contract  this  disease 
will  be  deformed  or  crippled  for  life  with  consequent  inability  t» 
work  or  provide  for  themselves. 

It  is  a  duty  you  owe  to  your  children  and  tho-c  <>f  your  neigh- 


IMMUNITY    FROM    POLIOMYELITIS.  241 

bors  to  exercise  every  precaution  in  preventing  the  continuance  and 
spread  of  this  disease,  and  unless  you  exert  yourself  in  this  matter, 
an  absolute  quarantine  of  all  cases  of  anterior  poliomyelitis  will  be 
declared  by  the  board  of  health,  which  will  inflict  great  hardship 
and  distress  not  only  upon  yourself,  but  upon  the  entire  city. 

Human  life  is  the  most  valuable  asset  we  possess,  and  it  must 
be  protected  at  any  cost. 

Special  emphasis  should  be  laid  on  the  suggestion  that 
all  children's  gatherings  be  discountenanced  by  the  local 
authorities,  such  as,  for  example,  picnics,  excursions,  public 
playgrounds,  theaters,  shows,  Sunday  schools,  etc. 

That  the  clothes  and  linen  used  by  the  household  be 
disinfected  and  excluded  from  the  public  laundry. 

That  the  school  committee  be  advised  to  extend  the 
vacation  a  fortnight,  thus  postponing  the  reopening  of 
schools  until  the  I9th  of  September  (the  school  committee 
were  unanimous  in  their  vote  on  this  question,  granting 
the  extension  of  the  vacation,  and  further  agreed  that  cases 
of  epidemic  poliomyelitis,  that  had  occurred  in  Springfield 
that  summer,  be  excluded  from  the  public  schools  for  at 
least  two  or  three  weeks  after  the  isolation  order  was 
raised),  and  that  a  special  placard  be  posted  on  all  the 
houses  in  a  conspicuous  place.  The  following  is  the  form 
used  in  Springfield: — 

KEEP  OUT. 

Anterior  Poliomyelitis. 

All  persons,  not  inmates,  are  forbidden  to  enter  this  building. 
BY  ORDER  OF  THE  BOARD  OF  HEALTH. 

Any  person  removing  this  card  without  authority  is  liable  to  a 
hue  of  from  $10  to  $100. 

2.  THE  PARALYTIC  ANIMAL  AND  COMMUNAL  PROPHYLAXIS. 

There  is  no  class  of  domestic  animals  nor  fowls  which 
lias  wholly  escaped  attack  from  epidemic  paralysis  coin- 

16 


242  1XFAXTILE    PARALYSIS. 

cidental  with  acute  poliomyelitis  in  the  human  family.  In 
some  communities  it  has  been  noted  that  colts  and  horses 
were  most  frequently  affected,  and  this  is  doubtless  due  to 
the  fact  that  sickness  of  an  animal  of  the  monetary  value  of 
the  horse  will  certainly  be  noted.  Frequently  dogs  have  be- 
come paralytic,  and  Langhorst,  of  Illinois,  observed  2.  cases 
of  acute  poliomyelitis  in  the  human  develop  from  canine 
infection.  A  notable  case  of  association  of  epidemic  paral- 
ysis of  animal  and  man  was  reported  by  Ely,  of  Iowa, 
during  the  Iowa  epidemic  of  191 1.  A  Boone  County,  Iowa, 
farmer,  observing  that  a  number  of  chickens  became  para- 
lytic, snapped  off  their  heads  and  threw  them  into  the 
hogpen;  later  in  the  summer  a  hog  developed  paralysis  of 
the  hind  quarters,  and  somewhat  later  the  farmer's  child 
developed  an  attack  of  acute  poliomyelitis,  which  was  at- 
tended by  Dr.  Ely.  Another  paralyzed  fowl,  being  ob- 
served on  the  farm  at  this  time,  was  submitted  to  the 
pathologist  at  Drake  University,  who  found  in  the  cord 
of  the  chicken  the  histologic  picture  of  acute  poliomyelitis 
in  man. 

Since  it  is  positively  known  that  the  biting  stable-fly 
is  the  agent  of  transmission  of  acute  poliomyelitis  from 
animal  to  man,  communal  protection  now  demands  the 
death  of  all  small  and  inexpensive  domestic  animals  which 
show  symptoms  of  paralytic  disease,  and  the  incineration 
of  their  bodies. 

In  the  case  of  more  valuable  animals,  the  horse,  blooded 
cattle,  sheep,  pedigreed  cats  and  dogs,  it  would  be  suffi- 
cient to  enforce  the  compulsory  screening  with  wire  mesh 
of  the  quarters  in  which  the  animals  are  confined,  with  a 
sanitary  maintenance,  which  inhibited  the  breeding  of  flies, 
of  all  environment.  The  owner  of  the  animal  should  be 
fully  informed  that  by  so  doing  he  is  maintaining  a  pos- 
sible menace  to  his  remaining  stock,  as  well  as  the  members 


IMMUNITY    FROM    POLIOMYELITIS.  243 

of  the  household  or  servant  staff.  This  is  a  large  and  as 
yet  uninvestigated  subject.  Our  present  knowledge  of  dis- 
ease carriers  would  suggest  to  the  thoughtful  that  the 
wry-necked  colt  and  the  poke-necked  horse  may  remain  a 
carrier  of  the  organism  of  poliomyelitis  for  life.  The  com- 
munity which  demands  the  destruction  and  incineration 
of  all  paralytic  animals,  and  at  the  same  time  gives  atten- 
tion to  the  insect  problem,  will  thus  assure  the  best  prophy- 
laxis to  its  citizens. 

The  Dog. — There  are  two  measures  which  should  be 
taken  by  every  community  and  made  permanent.  Dogs 
should  not  be  allowed  to  roam  at  large.  All  dogs  on  the 
street  or  public  highway  should  be  muzzled.  There  is 
abundant  evidence  that  poliomyelitis  and  rabies  are  so 
closely  allied  as  to  be  for  all  practical  purposes  classified 
as  identical  diseases.  The  sick  dog  while  in  the  febrile  or 
furious  stage  scatters  infection  by  biting  the  men  and 
animals  with  which  he  comes  in  contact.  During  this 
period  and  also  in  the  paralytic  stage  he  may,  through  the 
agency  of  biting  flies,  remain  a  source  of  infection  of  men 
and  animals.  As  muzzling,  while  needed,  is  only  a  partial 
protection,  the  sick  dog,  if  too  valuable  to  be  shot,  should 
be  kept  in  a  pen  screened  with  a  wire  mesh  which  will  ex- 
clude all  biting  insects,  his  pen  to  be  thereafter  burned  or 
disinfected  to  destroy  all  fleas. 

There  are  twro  ways  of  safely  disposing  of  the  body  of 
the  paralytic  animal.  It  may  be  incinerated  with  fire,  or 
buried  in  quicklime.  Never  under  any  circumstances 
should  the  paralytic  animal  be  fed  to  other  stock.  Burial 
is  equally  dangerous.  Proescher,  of  Pittsburg,  relates  that 
virulent  rabic  virus  was  found  present  in  the  body  of  a 
dog  which  had  been  buried  for  eight  months.  Pasteur 
found  that  earthworms  brought  anthrax  germs  to  the 
surface  from  the  bodies  of  sheep  which  died  of  that  dis- 


244  1XFAXTILE    PARALYSIS. 

ease  and  had  been  buried  in  somewhat  shallow  graves. 
The  physician  and  officer  of  the  health  board  should  adver- 
tise these  measures  through  the  local  press  and  with 
circulars. 

It  has  been  definitely  ascertained  that  animals  contract 
epidemic  poliomyelitis,  a  disease  whose  symptoms  are 
identical  with  the  so-called  rabies.  There  is  no  man  today 
who  can  state  with  authority  that  a  paralytic  animal  has 
contracted  rabies  and  has  not  contracted  acute  polio- 
myelitis. 

3.  BLOOD-SUCKING  INSECTS   PARASITIC  TO 
MAN.     PROPHYLAXIS. 

(a)  The  Stable-fly.     The  Barn-fly.     The  Rain-fly 
(Storrioxys  calcitrans). 

The  stable-fly  is  best  known  by  the  fact  that,  while  it 
closely  resembles  the  common  house-fly  in  appearance,  it 
bites,  which  the  house-fly  provided  only  with  a  sucking 
beak  cannot  do.  In  the  Mid-\Yest  it  is  best  known,  by  the 
name  of  its  characteristic  attribute,  as  the  biting  fly.  A 
frequenter  of  stables,  it  is  fairly  common  in  insanitary 
homes,  and  as  it  always  seeks  shelter  before  a  storm  the 
proverb,  "Flies  begin  to  bite  before  a  rain,"  became  tradi- 
tional. From  this  fact  the  insect  in  England  is  known  as 
the  rain-fly. 

The  biting  stable-fly  transmits  the  micro-organism  of 
infantile  paralysis  directly  from  the  blood  of  an  infected 
case  to  the  next  animal  or  man  which  it  attacks.  This  fly 
was  found  on  the  premises  of  a  majority  of  cases  of  polio- 
myelitis investigated  by  Sheppard  during  the  Massa- 
chusetts epidemic  of  1911.  It  is  the  writer's  belief  that 
the  stable-fly  is  the  common  agent  in  transmission  of  this 
disease  from  animal  to  man,  and  that  its  agency  between 
man  and  man  is  less  immediately  dangerous.  The  menace 


IMMUNITY    FROM    POLIOMYELITIS.  245 

of  its  presence  is  such,  however,  that  its  destruction  must 
be  achieved  by  the  sanitary  community. 

Methods  for  Destruction  of  the  Biting  Stable-fly  and 
Other  Flies. — Animal  excrement  and  especially  horse-drop- 
pings maintain  the  most  fertile  breeding  ground  for  flies. 
Garbage  which  is  left  exposed  about  houses,  hotels,  butcher 
shops,  and  slaughter  houses  will  be  found  alive  with 
maggots.  There  is  a  fly  in  the  MidAYest  which  maintains 
vast  breeding  places  on  the  borderline  of  fields  near  water, 
where  millions  of  flies  may  be  seen  breeding.  The  breeding 
places  of  flies  must  be  found  and  rendered  sterile.  The 
most  common  breeding  place  is  the  untended  stable.  The 
floor  of  a  horse-stall  which  is  not  cleaned  once  daily  will  be 
found,  during  warm  weather,  to  be  alive  with  maggots 
under  the  bedding. 

A  valuable  method  of  immediate  sterilization  of  stable 
manure,  as  used  on  a  model  farm,  is  here  given : — 

Mix  equal  quantities  of  acid  phosphate  and  German  kainit,  and 
throw  a  shovelful  in  the  gutter  back  of  each  horse  twice  daily.  The 
mixture  absorbs  the  liquid  manure,  prevents  manure  from  burning, 
adds  greatly  to  its  plant- food  value,  and  prevents  the  breeding  of 
rlies  in  the  manure.  Caution:  Do  not  allow  much  of  the  material 
on  the  platform  where  the  animals  stand,  as  it  might  make  their 
feet  sore  if  they  stood  constantly  on  it. 

In  addition  to  this  precaution,  the  manure  should  be 
kept  in  a  closed  container  which  is  provided  with  a  wrire- 
t rapped  airhole  to  catch  and  retain  any  flies  which  may 
breed  in  its  contents. 

The  tight  container  with  wire  fly-trap  at  top  should  be 
made  compulsory  for  domestic  garbage,  hotel  use,  and  the 
ground  bone,  offal,  etc.,  of  butcher  shops. 

Each  community  will  have  to  adjust  its  own  problems 
in  this  particular  and  will  find  sufficient  work  in  cleaning 
ui >  tne  detestable  fly-breeding  conditions  maintained  about 


246  INFANTILE    PARALYSIS. 

country  slaughter  houses,  canneries,  bakeries,  etc.  The 
communities  which  first  appreciate  the  value  and  enlist  the 
services  of  the  women  home-makers,  whose  interests  place 
them  above  the  graft  of  inspectors  appointed  by  the  local 
politicians,  will  first  attain  a  sanitary  condition  sufficiently 
excellent  to  halt  the  spread  of  any  epidemic  whose  germ 
is  blood-borne. 

The  fly-killing  fungus  which  has  been  grown  in  pure 
culture  by  Hesse,  Park  and  Copeman,  of  England,  has 
been  found  to  be  severely  pathogenic  to  house-flies,  and  it 
is  not  impossible  that  it  may  prove  to  be  destructive  to  other 
flies.  The  fungus  is  under  consideration  at  the  United 
States  Entomological  Bureau.  This  fungus  is  said  to  he 
so  fatal  to  flies  that  if  one  fly  is  inoculated  and  set  free,  an 
epidemic  spreads  among  flies  and  they  drop  ,by  thousands, 
to  be  gathered  up  and  burned.  The  fly  is  inoculated  by 
scratching  it  lightly  with  a  needle  which  has  been  touched 
to  a  pure  culture  of  the  fungus. 

Tanglefoot,  traps,  and  fumigation  are  as  effective  with 
the  biting  fly  which  gains  entrance  to  the  house  as  with  the 
house-fly.  A  new  method  of  poisoning  them  could  pos- 
sibly be  devised  with  fresh  bananas,  as  they  will  feed  on 
this  fruit,  but  are  said  to  not  frequent  nor  be  attracted  by 
•watery  solutions. 

(b)  The  Bedbug.     The   Indo-European  Bedbug 

(Cimex  Lectularius). 

"Creeping  things  from  which  corae  obscure  diseases."     Columella. 

62  years  r..  C. 

The  bedbug  is  probably  the  common  carrier  of  acute 
poliomyelitis  from  man  to  man,  and  its  extermination  is  the 
goal  to  be  aimed  for.  The  bedbug  must  be  excluded  by 
destruction  from  all  dwellings,  business  districts,  public 
halls  and  utilities,  hospitals  and  churches,  free  dispensaries 


IMMUNITY   FROM   POLIOMYELITIS.  247 

and  night  shelters,  rolling  stock,  and  passenger  ships.  An 
annual  spring  extermination  of  the  bedbug  will  result  as 
well  in  the  destruction  of  all  hibernating  house-flies  and 
house-mosquitoes,  cockroaches,  ants,  and  house-centipedes. 
An  annual  renovation  to  be  effective  must  include  not  the 
bed-chambers  of  a  house  only,  but  every  room  in  the  house; 
not  a  single  flat  in  an  apartment  house,  but  every  floor, 
including  the  basement ;  not  one  house  in  a  tenement  row, 
but  the  entire  block. 

Methods  for  Destruction  of  the  Bedbug. — The  methods 
to  be  employed  are  (i)  general,  including  fumigation  by 
hydrocyanic  acid  gas  or  brimstone,  or  destruction  by  fire ; 
(2)  local,  including  the  application  of  various  volatile  or 
other  poisons,  or  of  boiling  water. 

Hydrocyanic  acid  gas  method:  The  immediate  and 
complete  sterilization  of  a  building  and  all  its  contents,  with 
the  total  destruction  of  all  germs,  parasites,  and  vermin 
on  the  premises,  can  be  accomplished  by  fumigation  with 
hydrocyanic  acid  gas.  The  gas  penetrates  every  aperture, 
and  leaves  behind  it  the  death  of  every  organism;  the  dust 
will  be  undisturbed  but  innocuous ;  no  cockroach  or  water- 
bug  will  be  seen  about  the  plumbing;  no  bedbug,  moth, 
mosquito,  or  house-fly  will  emerge  from  any  crevice  or 
drapery.  Fumigation  by  this  method  is  so  exact  that  it 
should  be  in' common  use  at  least  once  a  year;  its  immediate 
effectiveness  recommends  it  for  use  in  all  aggravated  and 
intractably  insect-ridden  houses.  The  method,  however, 
is  both  expensive  for  individual  use,  and  dangerous  when 
employed  unintelligently.  Individual  experimental  use  of 
the  hydrocyanic  acid  gas  method  is  not  advocated.  It 
should  be  a  part  of  the  equipment  of  the  municipality  which 
is  placed  at  the  call  of  the  individual  citizen,  as  is  fire  pro- 
tection, and  should  be  compulsory  in  all  buildings  enumer- 
ated above  during  the  months  of  spring.  Annual  com- 


248  INFANTILE    PARALYSIS. 

pulsory  municipal  fumigation  can  be  accomplished  by 
municipal  ownership  of  equipment  and  sufficient  accessory 
apparatus  in  the  way  of  tents,  etc.,  to  house  for  twenty- 
four  hours  the  inhabitants  of  one  city  block,  notification 
to  be  given  one  week  in  advance.  The  hydrocyanic  acid 
gas  method  of  fumigation  of  houses  is  given  in  detail  by 
L.  O.  Howard,  Chief  of  the  United  States  Bureau  of 
Entomology,  in  Circular  Bulletin  46,  revised  edition.  In 
response  to  a  letter  of  inquiry  regarding  the  use  of  the 
hydrocyanic  gas  in  tenements,  Dr.  Howard  replied:  "In 
order  to  be  effective  and  safe  in  East  Side  tenements,  fumi- 
gation with  hydrocyanic  gas  should  only  be  carried  on  in 
the  central  one  of  three  vacated  buildings.  I  doubt  very 
much  whether  one  could  get  the  people  out  of  an  entire 
block  in  that  congested  quarter,  or  even  out  of  one  build- 
ing.'' Yet  it  is  in  the  slums  of  our  great  cities  in  which 
pestilence  breeds  and  from  which  it  spreads.  It  is  in  these 
slums  that  bedbugs  abound. 

Sulphur  fumigation :  It  is  sometimes  very  desirable  in 
the  eradication  of  parasites  to  fumigate  a  room  at  a  time, 
or  to  fumigate  several  rooms  successively.  Summer  camps 
and  seaside  cottages  may  be  infected  with  bugs  and  should 
be  fumigated  before  occupancy.  A  room  or  a  relatively 
small  house  can  be  satisfactorily  treated  by  sulphur  fumi- 
gation. Sulphur  will  bleach  books  or  draperies  and  all 
metal  will  tarnish.  The  sulphur  candle  is  convenient  for 
use.  Use  i  candle  for  a  closet  of  ordinary  size  and  for  a 
room  which  can  be  sealed  use  i  pound  of  sulphur  candles 
to  each  1000  cubic  feet  of  air  space.  It  will  not  be  neces- 
sary to  seal  a  vacant  frame  building,  but  it  will  be  neces- 
sary to  increase  the  amount  of  sulphur  to  2  pounds  for  each 
i  cxx>  cubic  feet  of  air  space  and  close  the  building  for 
treatment  at  least  twenty-four  hours.  The  sulphur  should 
be  placed  in  a  good-sized  receptacle  such  as  a  coal-hod, 


IMMUNITY    FROM    1'OLIOM VELIT1 S.  249 

which  should  be  placed  in  a  pan  of  water,  so  that  there 
may  be  no  overflow  of  the  burning  mass  to  start  a  con- 
flagration. Close  all  windows,  registers,  ventilators,  and 
large  apertures,  but  do  not  paste  up  broad  cracks  with 
strips  of  paper,  as  by  that  means  may  be  preserved  alive  the 
vermin  you  wish  to  destroy.  Ascertain  that  the  sulphur  is 
well  fired  and  burning,  and  close  up  the  room  or  cottage 
for  twenty-four  hours.  The  premises  should  be  well  aired 
for  a  day  succeeding  the  fumigation  before  occupancy. 

Destruction  by  fire :  When  small  structures  of  moder- 
ate value,  such  as  chicken-coops,  outside  closets,  and 
summer  camps,  have  become  infested  with  bedbugs,  the 
best  prophylaxis  is  incineration.  A  great  deal  of  old 
household  articles  stowed  about  the  country  house  should 
help  to  feed  the  fire.  Old  and  unused  bedsteads  of  wood, 
folding  beds,  picture-frames,  and  trunks  are  especially 
liable  to  be  infested.  The  rubbish  in  attics  becomes  infested 
with  bedbugs  brought  to  the  chimneys  by  swallows  and 
bats,  and  these  parasites  can  no  longer  be  considered  harm- 
less. Fire  can  be  used  effectively  in  freeing  an  iron  bed- 
stead which  is  thoroughly  infested  with  bugs;  bugs  some- 
times take  complete  possession  of  a  neglected  bed  in  an 
institution,  and  will  be  found  to  have  invaded  any  joint  or 
crevice  in  the  gas-pipe  of  which  it  is  often  constructed. 
The  bed  must  be  removed  to  a  concrete  floor,  or  out  of 
doors;  alcohol,  poured  about  all  crevices  and  joints  and 
immediately  fired,  will  destroy  every  bug  and  all  the  eggs; 
the  wire  springs  can  be  fired  by  passing  a  burning  news- 
paper torch  below  them. 

Local  application:  The  application  of  corrosive  sub- 
limate, the  petroleum  oils,  and  the  various  insecticides  is 
not  advocated  for  the  reason  that,  while  any  of  these 
agents  will  kill  a  certain  number  of  bugs,  -they  will  at  the 
same  time  drive  others  to  a  different  bed  or  another  room. 


250  INFANTILE    PARALYSIS. 

and  the  fight  must  be  soon  renewed;  also,  the  treatment  of 
a  few  pieces  of  furniture  or  a  portion  of  a  house  is  mere 
temporizing,  for  owing  to  the  secretive  habits  of  the  bed- 
bug a  small  number  only  will  be  destroyed.  \Yater,  poured 
from  the  teakettle  in  which  it  is  still  boiling,  will  kill  all 
bugs  and  eggs  on  the  area  to  which  it  is  applied.  Quick- 
silver, beaten  to  an  emulsion  with  egg  albumin,  is  very 
destructive,  as  the  bedbugs  will  feed  on  the  fresh  albumin 
and  die. 

As  it  is  possible  that  poliomyelitis  may  be  transmitted 
by  other  biting  insects  parasitic  to  man.  the  most  practical 
insecticides  and  methods  of  prophylaxis  for  the  flea  and 
mosquito  are  given : — 

Flea. — Usually  brought  to  house  by  dog  or  cat;  eggs 
deposited  on  rug  or  floor  of  animal's  bed.  Burn  the  bed- 
ding. Cover  the  floor  with  loose  crystals  of  naphthalin. 
allow  them  to  remain  for  twenty-four  hours,  then  sweep 
up :  may  be  used  again.  When  fleas  infest  a  living-room 
scatter  the  naphthalin  over  floor,  close  for  twenty-four 
hours,  and  sweep.  Five  pounds  of  naphthalin  are  suffi- 
cient for  a  medium-sized  room,  and  may  be  used  repeatedly. 
( Doane. ) 

Mosquito. — The  absolute  draining  of  all  standing  water 
will  largely  prevent  the  breeding  of  mosquitoes.  Screen- 
ing, fumigation,  the  burning  of  pyrethrum  powder,  and 
the  kerosene  cup  form  secondary  relief. 

"The  complete  destruction  of  the  blood-sucking  insect 
is  the  goal.  Though  it  may  never  be  reached,  yet  the 
reduction  in  numbers  and  the  gradual  elimination  from 
definite  areas  will  proportionately  reduce  the  dangers. 
This  warfare  demands  an  accurate  knowledge  of  every 
detail  of  the  life  history  of  these  insects,  the  appearance- 
presented  by  their  stages  of  development,  their  breeding 
places,  their  food,  the  length  of  the  period  of  development. 


IMMUNITY    FROM    POLIOMYELITIS.  251 

and  the  resistance  of  the  larval  and  other  stages  to  various 
destructive  agencies.  Often  a  very  weak  and  a  very  in- 
conspicuous link  in  the  chain  of  development  can  be  easily 
attacked,  and  life  thereby  destroyed,  or  breeding  rendered 
impossible."  (Theobald  Smith.) 

4.  CONTACT  CONTAGION  FROM  COMMON  CARRIERS. 

\Ye  know  that  the  organism  of  poliomyelitis  is  viable 
in  the  buccal  secretions  (saliva)  of  a  case  at  least  during 
the  acute  stage.  It  has  not  been  demonstrated  that  these 
secretions  render  the  disease  contagious,  but  it  cannot  be 
gainsaid  that  an  infection  from  these  secretions  might  be 
contracted  through  the  intermediary  of  household  or  public 
linen  or  the  public  drinking-cup. 

Federal  law  has  now  abolished  the  public  drinking- 
vessel ;  in  many  States  the  common  towel  has  been  abol- 
ished. Paper  cups,  paper  towels,  paper  handkerchiefs,  and 
paper  napkins  should  be  adopted  and  advocated  by  every 
sanitarian. 

FUMIGATION   OF  THE  COMMON  CARRIERS  OF 
MODERN  TRANSPORTATION. 

"An  entirely  healthy  Vienna  woman  of  25  years  spent  five  days 
in  Berlin  with  her  parents.  A  strong  draft  blew  through  the  sleeper 
on  her  way  to  Berlin.  On  her  return  she  developed  an  acute  ascend- 
ing poliomyelitis,  dying  in  stupor  on  the  ninth  day."  (Blum,  Wiener 
klinische  Wochenschrift,  Sept.  5,  1912.) 

One  of  my  husband's  men,  returning  from  Bridgeport  to  New 
York  a  summer  night  in  1912,  by  the  way  of  a  Sound  steamer, 
found  the  bedbugs  so  numerous  in  the  men's  ordinary  that  sleep 
was  not  possible;  on  complaining  to  the  clerk  he  was  informed  that 
the  only  thing  which  could  be  done  was  to  take  a  stateroom. 

There  are  cheap,  effective,  and  well-known  methods  for 
securing  the  destruction  of  blood-sucking  insects  which 
congregate  about  the  seats  and  sleeping  berths  of  common 


252  INFANTILE   PARALYSIS. 

carriers.  The  fumes  of  burning  sulphur  are  recognized 
as  a  standard  remedy  for  the  fumigation  of  barracks,  and 
under  the  name  of  Clayton  gas.  introduced  under  pres- 
sure, sulphur  dioxide  is  now  extensively  used  for  the  fumi- 
gation of  ships  and  their  cargoes. 

The  Engineering  News  of  August  29,  1912,  printed  the 
picture  of  a  tank  16.4  feet  wide  and  75.5  feet  long  for  dis- 
infecting passenger  coaches,  which  is  used  on  the  Prussian 
state  railways.  A  coach  is  rolled  in  on  rails,  the  door  is 
closed  and  hermetically  sealed,  a  partial  vacuum  is  pro- 
duced, and  steam  pipes  boiling  water  at  120°  F.  complete 
the  process  of  killing  all  vermin.  They  cannot  endure  the 
temperature  and  reduced  air-pressure  combined.  A  germi- 
cide in  vapor  form  is  then  introduced  to  destroy  all  bacteria. 

Fumigation  of  sleeping  cars  every  two  months,  with 
airing  and  cleansing  of  all  berth  clothing  at  the  end  of 
each  trip,  were  measures  proposed  for  State  legislation  at 
the  meeting  of  the  Northwestern  Railroad  Sanitation  Con- 
ference held  in  St.  Paul,  Dec.  5,  1912.  Measures  such  a< 
these  should  receive  the  support  of  every  physician,  and 
such  support  is  most  effectively  given  through  the  medium 
of  the  county  and  State  medical  societies. 

INDIVIDUAL  PROPHYLAXIS. 

Two  irequent  questions  asked  the  doctor  during  the 
appearance  of  poliomyelitis  in  a  community  are  :— 

What  can  I  give  the  children  so  they  won't  take  it? 

\Yhat  can  I  do  to  keep  from  getting  it  ? 

In  Wisconsin  in  1908  I  advocated  removal  to  an  unin- 
vaded  district  until  the  height  of  the  epidemic  had  passed: 
and  it  is  amazing  how  little  we  can  add  to  this  suggestion 
today,  although  we  realize  more  clearly  the  disadvantage 
to  the  uninvaded  community  of  such  visitations  from  an 
infected  district. 


IMMUNITY    FROM    POLIOMYELITIS.  253 

Environment. — Close  association  with  a  recent  case  of 
poliomyelitis  is  now  considered  undesirable ;  such  cases 
should  be  provided  with  a  separate  chamber  and  bed. 
Association  with  sick  animals  is  to  be  avoided  at  all  times. 
Domestic  pets  when  ill  should  be  isolated  as  certainly  as 
sick  children  until  the  character  of  the  illness  is  known. 
There  has  been  a  constant  association  in  the  recent  epi- 
demics of  coincidental  epidemic  paralysis  of  almost  every 
domestic  animal.  Cats,  dogs,  hogs,  chickens,  etc.,  para- 
lyzed after  acute  illness,  should  be  killed  and  their  carcasses 
burned;  but  it  may  be  easier  to  remove  one's  habitation 
than  to  insist  on  the  destruction  of  another's  property. 
The  individual  who  is  not  a  householder  should  see  that 
his  immediate  environment  is  sanitary,  or  remove  to  other 
lodgings.  A  chamber  should  have  bare  floors  and  little 
drapery,  should  be  mopped  once  a  week,  and  be  rlnnigated 
with  sulphur  if  there  is  a  possibility  of  vermin.  School- 
teachers should  ascertain  that  the  schoolrooms  in  which 
the  day  is  passed  are  sterile  and  free  from  dust,  even 
though  an  appeal  must  be  taken  to  the  schoolboarcl  to 
secure  it. 

Personal  cleanliness  is  also  a  factor  in  prophylaxis. 
Public  linen  and  public  drinking-cups  are  to  be  avoided. 
This  applies  to  the  cup  on  the  highway ;  also  applies  to  the 
tumbler  of  water  passed  about  among  a  group  of  friends 
at  a  social  game  of  cards  or  elsewhere,  for  we  cannot  ignore 
the  fact  that  poliomyelitis  as  well  as  many  other  diseases 
may  be  transmitted  from  the  secretions  of  the  nose  and 
throat. 

Immunity  and  Immunization. — A  relative  spontaneous 
immunity  to  poliomyelitis  seems  to  be  possessed  by  some 
fortunate  individuals;  it  is  demonstrated  not  so  much  by 
the  members  of  a  family  who  wholly  escape  as  by  the  large 
percentage  of  cases  of  the  arrested  type :  people  who  have 


254  1XFAXT1LE   PARALYSIS. 

taken  the  infection,  but  seem  to  be  able  to  at  once  shake  it 
oft".  A  free,  natural  elimination  would  seem  to  be  the  factor 
in  this  resistance,  and  the  theory  is  supported  by  experi- 
mental proof, — the  artificial  production  of  the  disease  in 
monkeys  by  way  of  the  digestive  tube  was  unsuccessful 
until  the  digestion  was  inhibited  by  opium. 

Artificial  immunity  to  poliomyelitis  may  perhaps  be  ac- 
quired by  the  most  rigorous  attention  to  elimination.  Calo- 
mel every  second  or  third  week-end,  cascara  sagrada  daily 
at  bedtime,  and  copious  drinking  of  pure  water  at  and 
between  meals  are  excellent  measures  to  advocate  to  the 
sedentary  American.  Better  than  the  advocacy  of  any 
particular  measure  is  to  convince  an  individual  of  the  fecal 
residue  forming  an  excellent  culture  media  for  germs 
which  remain  in  his  or  her  digestive  tube  after  the  "regular 
daily  movement." 

Serologic  immunization  has  been  attained  for  the  ape, 
but  no  serum  immunity  for  man  has  yet  been  perfected. 

Medication. — The  most  important  medication  in  polio- 
myelitis, the  use  of  eliminants,  has  just  been  discussed. 

Internal  Antiseptics. — Hexamethylaminetetramine  has 
been  advocated  for  use  in  the  prophylactic  treatment  of 
infantile  paralysis,  as  it  has  been  recovered  from  the  spinal 
fluid  one-half  hour  after  ingestion.  Its  usefulness  is  ques- 
tioned by  others,  while  its  known  action  as  an  irritant  to 
the  bladder  suggests  caution  in  prescribing  it  to  children. 
A  reliable  intestinal  antiseptic,  which  is  recommended  after 
years  of  use  in  general  practice,  is  bismuth  betanaphthol. 
I  would  suggest  that,  at  least  in  childhood,  this  drug  be 
substituted  for  the  preparations  of  formaldehyde. 

Disinfection  of  Xosc  and  Throat. — The  individual  who 
does  not  make  use  of  peroxide  of  hydrogen  as  a  dentifrice 
is  advised  to  add  it  to  his  toilet  table.  Peroxide  is  the  most 
advocated  of  all  disinfectants  in  the  prophylaxis  of  polio- 


IMMUNITY    FROM    POLIOMYELITIS.  255 

myelitis,  as  a  i  per  cent,  solution  is  said  to  destroy  the  virus. 
It  is  an  excellent  dentifrice,  and  its  use  as  such  insures  a 
constant  rather  than  a  spasmodic  cleansing  of  the  mouth 
and  throat.  It  is  also  an  excellent  gargle.  I  do  not  advo- 
cate its  use  as  a  nasal  douche,  as  it  oxidizes  tissue  so  rapidly 
as  to  unpleasantly  clog  the  nares.  The  nasopharynx  may 
be  cleansed  daily  with  the  following  antiseptic  spray  :— 

1^   Thymolis gr.  xv. 

Sodii  boratis, 

Sodii  bicarb aa  gr.  Ix. 

Fl.  ex.  pinus  Canad 553. 

Glycerini    ^j. 

Aquse   q.  s.  ad  .^iv. 

For  atomizer  use  i  dram  to  i  ounce  of  warm  water. 

NASAL  ANTISEPTICS.    A  WARNING. 

The  appended  article  by  Dr.  Emil  Krulish,  P.  A. 
Surgeon,  U.  S.  Public  Health  Service,  was  written  from 
Texas  during  the  epidemic  of  cerebrospinal  meningitis  of 
1912: — 

The  present  epidemic  of  cerebrospinal  meningitis  in  various 
portions  of  the  State  of  Texas  and  the  prevailing  fear  of  its  con- 
tagion by  the  public  demonstrate  that  the  question  of  prophylaxis 
is  of  most  vital  interest  and  importance.  It  is  encouraging  to 
those  interested  in  public  health  work  to  note  the  interest  that  the 
public  is  taking  in  preventive  medicine.  The  profession  is  consulted 
daily  by  the  laity  about  some  prophylactic  which  would  ward  off 
the  disease. 

All  epidemics  teach  the  inhabitants  of  the  invaded  sections 
that  "prevention  is  better  than  cure,"  and  the  people  of  Texas  have 
realized  this  fact,  for  wherever  a  case  of  meningitis  has  occurred 
the  health  authorities  have  improved  the  sanitary  conditions  of  that 
locality.  The  late  plague  infection  in  San  Francisco  is  responsible 
for  the  fact  that  it  is  considered  today  to  be  the  cleanest  city  in  the 
United  States. 

The  preventive  measures  against  cerebrospinal  meningitis 
usually  advocated  by  the  profession  are :  isolation  of  patients  and 


256  IXFAXT1LE    PARALYSIS. 

contacts;  prompt  report  of  cases  and  suspects  to  the  proper  health 
authorities;  disinfection  of  premises  previously  occupied  by  the 
diseased;  closing  up  of  places  of  public  gatherings  and  antiseptic 
gargles  and  nasal  sprays. 

It  is  to  the  last  measure,  the  application  of  antiseptics  in  any 
form  to  the  nasopharynx  as  a  preventive  in  cerebrospinal  meningitis, 
that  I  take  exception.  I  am  of  the  opinion  that  these  applications 
used  promiscuously,  as  they  are  by  the  public,  are  worthless,  if  not 
directly  injurious. 

In  order  to  direct  a  successful  and  an  intelligent  campaign 
against  any  epidemic  it  is  essential  for  us  to  understand  precisely 
the  manner  in  which  the  disease  is  transmitted  from  one  individual 
to  another  and,  in  infectious  diseases,  the  method  of  invasion  of  the 
organism.  Prior  to  the  demonstration  of  Lazear  and  his  associate-- 
that yellow  fever  was  transmitted  by  the  mosquito,  our  effort-  to 
eradicate  this  disease  were  in  vain.  \Ye  know  the  exciting  cause  of 
cerebrospinal  meningitis  to  be  the  Diplococcns  intraccllnlaris  mcnin- 
gitidis,  and  it  appears  that  the  primary  seat  of  attack  is  in  the  naso- 
pharynx, but  the  connecting  link  between  the  nasopharynx  and  the 
spinal  canal  is  still  missing  and  until  this  is  established  we  are  at 
sea  when  considering  the  subject  of  prophylaxis.  The  meningo- 
coccus  has  been  demonstrated  in  the  secretions  from  the  naso- 
pharynx, both  in  typical  cases  of  the  disease,  as  well  as  in  per-on- 
who  developed  no  symptoms  at  all. 

Advocates  of  the  nasal  spray  presumably  anticipate  the  destruc- 
tion of  the  micro-organisms  in  situ.  It  is,  however,  obvious  that 
any  antiseptic  in  a  solution  sufficiently  powerful  to  destroy  these 
germs  would  be  deleterious  to  the  mucous  membrane.  The  nasal 
chamber  with  its  turbinate  bodies  and  mucous  membrane  lined  with 
ciliated  epithelium  is  especially  adapted  to  prevent  germs  from 
passing  into  the  system,  which  is  demonstrated  by  finding  the 
tubercle  bacillus,  pneumococcus,  diphtheria  bacillus  and,  as  pre- 
viously stated,  the  meningococcus  in  the  secretions  of  apparently 
healthy  individuals.  The  nasal  mucous  membrane,  therefore,  pos- 
sesses a  high  degree  of  phagocytic  power. 

The  frequent  spraying  and  douching  of  the  nose  has  a  tendency 
to  injure  this  very  delicate  membrane  and  to  destroy  its  function, 
thus  defeating  the  primary  object  in  view.  The  specialist  has  long 
recognized  this  fact  and  has  discarded  the  use  of  the  compression 
tank  and  pump. 


IMMUNITY    FROM    POLIOMYELITIS.  257 

It  is  an  accepted  fact  that  the  exciting- cause  of  phthisis  is  the 
tubercle  bacillus,  which  is  taken  into  the  respiratory  tract  by  inhala- 
tion through  the  nose,  and  one  is  almost  constantly  exposed  to  this 
infection,  yet  no  one  prescribes  antiseptic  nasal  sprays  for  the  pre- 
vention of  tuberculosis;  we  endeavor  to  promote  the  function  of  the 
nasal  mucous  membrane  and  restore  it  to  its  normal  condition  if 
diseased. 

Let  us  consider  the  use  and  results  of  the  so-called  antiseptic 
spray  and  douche.  Spraying  of  the  nose  is  accomplished  by  means 
of  various  forms  of  atomizers;  their  action  is  chemical  or  mechani- 
cal. The  solutions  recommended  for  this  purpose  are  aqueous,  as 
Dobell's,  or  oily,  as  liquid  petrolatum,  with  eucalyptus  or  menthol. 
The  oily  solution  is  introduced  into  the  nose  in  the  .form  of  a  very 
line  vapor  and,  therefore,  any  benefit  derived  is  necessarily  chemical 
in  nature,  depending  on  its  antiseptic  properties.  Taking  for 
granted,  however,  that  it  is  germicidal,  we  know  from  experience 
how  difficult  it  is  to  reach  the  posterior  portion  of  the  nasal  cavity 
with  any  form  of  a  spray.  The  germs  which  may  be  present  in 
these  parts  would,  therefore,  be  beyond  the  firing  line  and  remain 
undisturbed. 

The  aqueous  solutions  when  used  in  the  form  of  a  spray  can 
act  but  chemically,  but  if  introduced  in  sufficient  quantities  or  as  a 
douche  the  chief  action  is  mechanical ;  the  germs  may  be  dislodged 
and  perhaps  washed  out  with  the  fluid.  I  kit  what  actually  occurs 
in  the  majority  of  cases  is  this  :  The  bacteria  are  perhaps  dislodged  ; 
the  nasal  cavity  then  contains  more  or  less  of  the  solution  and  the 
person  invariably  attempts  to  expel  it  by  blowing  the  nose.  Instead 
of  closing  one  nostril  and  blowing  the  other,  which  is  the  proper 
way.  the  act  is  performed  by  closing  the  mouth  and  compressing 
both  nostril >  simultaneously,  using  the  expanded  lungs  as  a  bellows. 
This  forces  the  air  up  into  the  nasopharynx,  where  it  is  condensed 
under  more  or  less  pressure ;  the  Eustachian  tubes  open,  and  some 
of  the  secretions  with  the  organisms  are  very  liable  to  be  forced  into 
the  middle  ear  and  perhaps  into  the  accessory  nasal  sinuses.  Thus 
the  germs  instead  of  being  expelled  are  distributed  through  the 
head,  where  they  usually  find  a  favorable  culture  medium  for  their 
growth  and  infection  is  likely  to  develop. 

I  f  the  theory  of  the  nasal  douche  were  efficacious,  the  postnasal 
douche  would  be  the  proper  method  of  cleansing  the  nasal  chamber 
and  expelling  organisms  which  may  be  present ;  a  small  catheter  or 


258  1XFAXT1LE   PARALYSIS. 

the  tip  of  a  syringe  introduced  through  the  mouth  into  the  post- 
nasal  space,  and  the  solution  allowed  to  flow  through  the  cavity 
forward  and  out,  thus  actually  washing  out  the  nose.  This  method, 
of  course,  is  not  practical  for  the  general  use  of  the  laity  except 
under  the  direction  of  the  physician. 

CONCLUSIONS. 

Xasal  sprays  as  ordinarily  used  for  prophylaxis  against  cere- 
brospinal  meningitis  are  unnecessary  because  of  the  obscure  etiology 
of  the  disease.  They  do  not  destroy  the  germs.  It  is  impossible 
to  reach  every  portion  of  the  nasal'  chamber,  and  a  normal  naso- 
pharynx is  usually  able  to  take  care  of  itself.  They  are  injurious 
from  the  fact  that  their  use  is  likely  to  give  the  person  a  sense  of 
false  security  and  he  is  apt  to  consider  other  measures  as  being  of 
minor  importance;  also  the  frequent  use  of  the  spray  injures  the 
delicate  mucous  membrane  and  lowers  its  vitality.  Therefore,  let  us 
leave  well  enough  alone  as  regards  the  nose.  (Kmlish.  "Cerebro- 
spinal  Meningitis,"  Jour.  Amer.  Med.  Assoc.,  Feb.  24.  1912.) 

The  physician  who  advocates  and  places  much  weight 
on  nasal  and  buccal  antisepsis  as  the  only  prophylactic 
measure  called  for  during  an  epidemic  of  poliomyelitis 
should  recall  that,  although  such  measures  have  been  so 
generally  accepted,  the  patent-drug  man  advertises  a 
nose  jelly  as  a  sure  preventive  of  infantile  paralysis,  yet 
this  method  of  transmission  of  poliomyelitis  by  nasal  and 
buccal  secretions  remains  unproi'cn.  The  flaw  in  the 
Flexner  theory  of  nasal  transmission  is  the  failure  to  get 
secondary  cases  in  institutions.  I  have  many  times  ob- 
served that  an  influenza]  infection  once  introduced  into  a 
hospital  goes  through  it  like  a  cyclone,  invading  the  rooms 
of  private  patients  with  quite  the  same  rapidity  of  progress 
as  through  the  wards.  There  is  also  the  known  epidemio- 
logic  law  that  respiratory  infections  attain  their  maximum 
in  the  winter  and  closed-in  season,  while  poliomyelitis  has 
so  far  attained  the  maximum  curve  of  incidence  in  the 
summer  months. 


IMMUNITY    FROM    POLIOMYELITIS.  259 

PROPHYLAXIS  FOR  THE  PHYSICIAN. 
A  very  large  number  of  cases  have  developed  in  the 
families  of  physicians  attending  acute  poliomyelitis.  Har- 
bitz  reports  9  cases  which  occurred  in  the  household  of 
one  physician  while  attending  cases.  The  following  un- 
usual suggestions  may  well  have  the  consideration  of  the 
doctor  attending  these  cases.  The  doctor's  driving  horses 
should  have  protection  from  flies.  The  doctor  should  re- 
quest a  plain  wooden  chair  when  in  the  sick  chamber,  and 
strike  it  on  the  floor  before  sitting  down,  ascertaining  at 
the  same  time  that  his  garments  do  not  come  in  contact 
with  the  bed-hangings,  from  which  bedbugs  will  crawl  to 
the  clothing  of  a  fresh  host  with  wonderful  celerity  and 
secrecy.  The  following  routine  prophylaxis  was  employed 
by  Dr.  Philip  A.  E.  Sheppard,  Special  Investigator  of  Epi- 
demic Poliomyelitis  for  the  Massachusetts  State  Board  of 
Health  :- 

(a)  \Yashing  of  hands  with  soap  and  water  before  and 
after  handling  patients,  excretions,  etc. 

(b)  After  handling  patient  and  washing  the  hands, 
further  rinsing  in  bichloride  of  mercury  or  equal  parts  of 
boric  acid  and  chloride  of  lime. 

(c )  Final  rinsing  in  alcohol,  70  per  cent. 

The  following  measures  were  carried  out  as  often  as 
practicable,  especially  before  mixing  in  the  company  of 
healthy  people  :— 

(d)  Antiseptic  mouth- wash  and  gargle  with  hydrogen 
peroxide  or  glycothymolin. 

ic]    Eye  douche  with  boric  acid. 

(  f  )    Xasal  spray  with  menthol  preparation. 

Einally,  after  seeing  the  last  case  for  the  day,  all  clothes 
worn  and  other  articles,  including  the  bag  in  which  they 
were  carried,  were  placed  in  a  sealed  cupboard  and  ex- 
posed overnight  to  the  influence  of  formaldehyde  gas. 


CHAPTER   XI. 

Treatment  of  Preparalytic  Stage,  and  Progress- 
ive Ascending  or  Descending  Paralysis  with 
Impending  Paralysis  of  Respiration. 


TREATMENT   OF   PREPARALYTIC   STAGE. 

TREATMENT  of  the  early  stage  of  poliomyelitis  is  of 
grave  importance  and  should  not  he  delayed  during  the 
stage  of  invasion  while  the  diagnosis  is  yet  doubtful,  for 
the  diagnosis  of  this  disease  in  many  instances  is  not  made, 
or  made  but  tentatively,  until  the  oncoming  of  paralysis. 
Much  may  be  accomplished  with  a  twelve-hour  start  of  the 
paralysis,  and  should  paresis  already  impend  with  one  ex- 
tremity presenting  the  aura  of  motor  weakness,  by  effect- 
ing prompt  and  certain  elimination  and  the  dilution  of  the 
toxins  distributed  by  the  blood-stream  to  spinal  fluid  and 
ganglion  cells,  it  may  be  possible  to  avert  an  ascending 
paralysis  and  death. 

Recalling  that  a  toxin  may  have  instituted  a  destructive 
and  constantly  augmented  action  on  the  ganglion  cells  of 
the  central  nervous  system,  and  realizing  that  every  hour 
between  the  onset  of  poliomyelitis  and  the  appearance  of 
paralysis  is  a  sixty-minute  opportunity  for  preventing  dis- 
ability or  death,  the  treatment  to  be  promptly  instituted, 
when  symptoms  may  indicate  and  do  not  negative  the  stage 
of  onset  of  poliomyelitis,  consists  of:  isolation;  confine- 
ment to  bed;  forced  feeding  of  water;  colonic  flushr 
repeated  until  elimination  is  established;  application  of  ice 
to  head  and  spine:  evacuation  of  bladder:  calomel;  mag- 
(260) 


TREATMENT    OF    PKEPARALYT1C    STAGE.  261 

nesia;  written  orders,  and  a  check  system  to  insure  their 
faithful  enforcement. 

In  the  majority  of  these  cases  seen  first  in  the  acute 
stage,  while  diagnosis  may  be  doubtful,  there  is  no  ques- 
tion the  patient  is  suffering  from  a  profound  toxemia.  The 
child,  the  young  male,  as  the  case  may  be,  is  found  with  a 
flushed  and  strained  countenance;  head  a  trifle  retracted; 
neck  more  or  less  rigid;  muscles  twitching;  headache 
basilar,  occipital,  or  very  occasionally  frontal,  and  a  tender 
spine.  There  will  be  a  history  of  change  in  disposition, 
tremor,  inco-ordination,  ataxia,  a  stumbling  gait,  or  unac- 
customed falls.  There  will  be  a  complete  paresis  of  diges- 
tion, evidenced  by  vomiting  and  obstipation,  with  abdominal 
pain  and  meteorism.  The  pulse  rate  will  be  much  aug- 
mented and  the  temperature  elevated,  while  respiration 
rate  will  be  unaccountably  increased.  Some  delay  in  void- 
ing the  urine  always  is  present,  retention  is  frequent,  and 
retention  with  overflow  may  mask  the  paralysis  of  bladder. 

\Yhat  is  first  called  for?  Elimination.  To  secure  in- 
telligent co-operation  from  the  parents  or  nurse  this  must 
be  explained  and  forcibly  impressed  on  them.  Leave 
written  orders,  or,  better,  do  not  leave  the  case  until  elimi- 
nation is  established. 

First  Aid. — Forced  feeding  of  water  is  first  aid  in  these 
cases.  Give  an  ounce  or  more  of  ice-water  every  fifteen 
minutes,  remembering  that  at  Hopkins  they  control  tem- 
perature in  the  typhoid  wards  by  the  forced  feeding  of 
water.  The  forced  feeding  of  water  in  the  acute  stage  of 
poliomyelitis  will 

(a)  dilute  toxins  in  blood  and  spinal  fluid  which  have  been 

proven  infectious  during  acute  stage ; 

(b)  decrease  plus  pressure  of  spinal   fluid,  by  lowering 

specific  gravity  of  blood  and  so  checking  hyper- 
osmosis  ; 


262  1X1-AXT1LE   PARALYSIS. 

(c)  wash  out  stomach  by  assisting  the  vomiting; 

(d)  flush  kidneys,  stimulate  renal  function,  and  increase 

amount  of  urine. 

Further  augment  this  flushing  of  the  system  with  re- 
peated colonic  lavage,  using  pure  water  at  body  tempera- 
ture with  the  addition  of  dissolved  ivory  soap  if  it  becomes 
apparent  that  the  digestive  tube  is  paretic.  The  absorption 
of  water  at  this  stage  is  most  important;  toxins  are  pro- 
moting hyperosmosis  from  the  nervous  tissue;  the  spinal 
fluid  has  increased  in  quantity,  until  the  pressure  is  un- 
bearable. Novi  maintained  that  the  origin  of  uremic  con- 
vulsions is  due  to  withdrawal  of  water  from  the  cortex 
cerebri.  Reducing  the  specific  gravity  of  the  blood  will  at 
once  set  in  action  forces  tending  to  check  this  osmosis.  If 
no  evacuation  from  the  bowels  is  secured  from  these 
measures,  a  mixture  of  equal  parts  of  glycerin  and  mag- 
nesium sulphate,  added  to  the  enema,  will  unload  the  lower 
bowel,  and  to  cleanse  the  entire  tract  calomel  should  be 
used.  An  immediate  effect  is  desired;  therefore,  give  the 
full  dose  of  calomel  at  once,  2  grains  for  a  child,  3  to  5 
grains  for  an  adult ;  follow  in  one-half  hour  with  the  pedia- 
trician's friend,  carbonated  effervescent  citrate  of  mag- 
nesia; a  feverish  child  will  drink  this  greedily  under  the 
name  of  lemonade,  and  the  castor-oil  struggle  has  been 
avoided. 

Examine  the  bladder;  if  there  is  distention,  with  in- 
ability to  micturate,  catheterize,  unless  other  methods  of 
relief  have  succeeded. 

Place  an  ice-bag  to  the  spine,  and  one  well  against  the 
nape  of  the  neck.  Children  with  the  burning  fever  of  the 
onset  of  poliomyelitis  find  some  relief  from  the  ice  applica- 
tions, and  will  ask  for  the  ice  when  it  has  been  removed. 
Many  of  these  children  present  the  appearance  of  heat- 
stroke, and  some  of  them  have  taken  violent  means  to 


TREATMENT    OF    PREPARALYT1C    STAGE.  263 

secure  relief  from  the  fever  in  their  veins,  notably  the 
12-year-old  boy  reported  by  Dr.  Marquardt,  of  La  Crosse, 
who  crawled  under  a  garden  sprinkler,  and  was  found 
there  in  the  acute  stage  of  poliomyelitis.  Pulmonary 
symptoms,  beyond  the  increased  respiration  which  is  cen- 
tral, contraindicate  any  but  the  most  intelligent  use  of  the 
ice-bag  in  children. 

An  emergency  ice-bag  can  be  readily  prepared  from  the 
inner  tube  of  a  worn-out  automobile  tire.  Cut  out  a  sec- 
tion, fill  with  ice,  turn  the  ends  over,  and  tie  tightly. 

GENERAL    TREATMENT. 

Isolation. — \Yhen  poliomyelitis  is  suspected  the  patient 
should  be  promptly  isolated  and  this  isolation  should  be 
maintained  in  its  entirety.  The  reasons  for  this  isolation 
apply  with  equal  force  for  the  benefit  of  the  individual 
himself,  the  family,  and  the  community.  It  conduces  to 
the  quiet  of  the  sickroom  to  permit  no  coming  and  going, 
and  quiet  is  most  desirable.  Rigid  exclusion  will  protect 
the  patient  from  contact  with  any  influenzal  or  respira- 
tor}- infection,  a  dangerous  and  fatal  complication  with 
paraly.sis  of  the  upper  segment  and  chest  muscles.  While 
we  remain  in  ignorance  of  the  method  of  transmission  of 
poliomyelitis,-  it  is  possible  that  the  most  innocent  visitor 
should  transmit  the  infection  to  a  third  person.  Evidence 
accumulates  that  this  disease  is  transmitted  bv  an  insect 

j 

host,  and,  should  that  host  prove  to  be  the  bedbug,  any 
visitor  to  the  sickroom  might  harbor  and  carry  away  the 
agent  of  transmission.  It  is  believed  by  many  physicians 
who  have  dealt  with  this  disease  in  its  epidemic  form  that 
isolation  and  postfumigation  will  check  the  spread  of  the 
disease. 

The  patient's  room  should  be  screened  from  flying  in- 
sects, and  bare  and  clean  as  a  hospital  ward;  if  climate 


264  IXFAXTILE    PARALYSIS. 

and  season  permit,  the  isolation  is  best  carried  out  in  a 
tent  with  a  wood  floor.  A  screened-in  sleeping  porch 
shares  with  a  tent  the  great  advantage  of  a  constant  sup- 
ply of  fresh  air  to  lungs  which  may  have  lost  more  or  less 
wholly  their  power  of  expansion  from  paresis  of  the  respi- 
ratory muscles.  The  sudden  advent  of  respiratory  paral- 
ysis may  occur  in  any  case,  and  preparations  for  removal 
to  fresh  air  should  be  adequate. 

Rest. — Absolute  rest  in  bed  from  onset  of  the  disease 
is  an  important  measure  in  the  treatment  of  poliomyelitis. 
The  mildest  case  may  suffer  a  reinvasion  of  the  attack,  and 
the  mortality  rate  is  kno\vn  to  increase  with  exertion  after 
onset.  In  many  cases  the  prostration  is  so  marked  before 
appearance  of  paralysis  that  this  measure  is  self-enforced. 
\Yhen  otherwise,  the  infraction  of  the  rule  may  be  pre- 
vented by  ascertaining  that  a  bedpan,  and  not  a  commode, 
is  provided,  that  drinking-water  is  conveniently  placed  on 
a  chair  or  low  table  beside  the  patient,  etc.  The  mere 
looking  after  such  details  by  the  physician  impresses  on 
the  mind  of  the  attendant  that  the  orders  are  more  than 
routine.  When  extreme  restlessness  is  manifest,  sedative 
measures  of  value  are  the  employment  of  the  ice-bag, 
cool  sponging,  immersion  bath  (given,  not  taken),  and 
codeine. 

Position. — A  child  will  show  gratitude  for  gentle 
changes  in  position,  and  it  is  questionable  whether  they 
should  be  allowed  to  rest  continuously  on  the  back,  although 
many  cases  with  the  preceding  pain  in  and  paralysis  of 
both  legs  prefer  that  position.  A  little  girl,  who  objected 
to  the  slightest  shifting  to  one  side  and  support  with  a 
tucked-in  pillow,  allowed  this  change  when  an  ice-bag  wa> 
interposed  between  the  spine  and  pillow,  and  a  flat,  soft 
pad  was  placed  under  the  superimposed  leg.  Armstrong,  of 
Minnesota,  reports  a  boy  of  5  years  who  for  a  week  lay  on 


TREATMENT    OF    PREPARALYTIC    STAGE.  265 

his  face  because  it  hurt  his  neck  to  lie  on  his  back.  The 
head  may  be  arranged  over  a  small,  flat  pad,  in  an  ex- 
tended position,  and  the  warm  pillow  eliminated.  Every 
case  must  be  studied  and  its  needs  consulted  in  this  matter 
of  position,  where  groups  of  muscles  are  spastic  from  pain 
and  exquisitely  tender  to  pressure  or  touch.  Do  not  make 
the  mistake  of  applying  any  method  of  rigid  immobiliza- 
tion to  these  tender  and  anguished  frames.  The  inquisition 
furnished  no  more  cruel  measure  than  the  application, 
which  has  been  advocated,  of  a  plaster  jacket  during  the 
acute  stage  of  poliomyelitis.  It  has  been  advocated  to  ''im- 
mobilize the  spine  during  the  period  of  muscular  excitabil- 
ity, as  we  would  any  acutely  inflamed  joint  with  muscular 
spasm."  Some  of  these  children  lie  rigid,  "stiff  as  a  log 
from  head  to  heels,"  and  the  advantage  of  artificial  immobi- 
lization is  not  obvious  in  these  cases ;  the  majority  of  chil- 
dren and  adults  present  a  beginning  opisthotonos ;  the 
mildest  form  may  be  that  of  a  nuchal  rigidity,  with  the 
head  slightly  extended ;  the  severe  grade  is  hyperextension 
of  spine  to  the  bent-bow  outline  from  head  to  buttocks,  with 
extreme  flexion  of  leg  on  thigh.  If  measures  which  assist 
relaxation  are  not  promptly  inaugurated,  inexorable  nature 
pursues  her  own  method  of  relaxation  and  a  flaccid  paral- 
ysis ensues.  Would  "immobilization  of  the  spine"  secure 
such  relaxation;  or,  indeed,  would  it  lessen  in  any  degree 
the  convulsive  twitching  of  the  quadratus,  or  peroneal,  or 
shoulder  group  of  muscles? 

The  disadvantages  of  permitting  a  continuous  dorsal 
decubitus  are:  a  possible  hypostatic  congestion  augment- 
ing the  spinal  congestion  of  the  lesion;  the  initiation  of 
bed-sores,  which  have  given  serious  trouble  when  trophic 
disturbance  accompanied  the  motor  and  sensory  changes, 
and  the  very  real  danger  of  hypostatic  congestion  of  the 
lungs  should  respiratory  paralysis  present. 


266  1XFAXT1LE    PARALYSIS. 

Air  or  water  beds  are  desirable  to  minimize  pain  by 
distributing  pressure,  and  thus  secure  the  maximum  of 
rest  and  sleep.  If  they  cannot  be  obtained,  it  will  be  found 
of  advantage  to  shift  the  position  of  the  patient  occa- 
sionally, giving  support  to  the  aching  extremities  while 
avoiding  the  use  of  heat-retaining  feather  pillows ;  to  ascer- 
tain that  only  sufficient  bed-covers  are  employed  (and  a 
sheet  is  sufficient  on  a  warm  day,  while  the  temperature 
remains  elevated) ;  to  suspend  these  coverings  over  a  large 
cradle  in  case  the  weight  is  in  the  least  irksome  to  the 
patient. 

n.vclitsion  of  Light. — The  majority  of  cases  suffer  from 
photophobia,  which  is  easily  understood  when  we  recall  the 
relative  size  of  the  optic  nerve,  its  great  peripheral  termina- 
tions, and  the  fact  that  autopsies  have  shown  that  a 
majority  of  cases,  even  of  the  spinal  type,  present  lesions 
of  the  cerebral  cortex.  Total  blindness  results  in  some 
of  the  encephalic  cases.  The  exclusion  of  direct  rays  of 
light  from  the  eyes  of  the  patient  should  be  accomplished 
by  some  other  method  than  darkening  the  room,  for  the 
reason  that  a  darkened  room  is  usually  accompanied  with 
a  stuffy  atmosphere  and  little  ventilation.  It  is  well  to 
place  the  bed  with  the  headboard  toward  the  wind<>\\^ 
which  receive  sunshine,  and  it  is  often  sufficient  and  con- 
venient to  merely  arrange  the  patient  with  head  at  the  foot 
of  the  bed.  Direct  rays  of  light,  whether  natural  or  artifi- 
cial, should  not  fall  in  the  direction  of  the  patient's  vision. 
Movable  screens  and  shades  may  be  utilized  in  these 
arrangements.  All  draperies  should  be  abolished  from  the 
sickroom. 

Before  going  on  to  the  medication  of  poliomyelitis,  I 
would  like  to  dwell  a  moment  on  the  difficulty  of  obtaining 
the  enforcement  of  such  simple  hygienic  measures  as  are 
noted  in  the  foregoing.  Many  good  people  consider  that 


TREATMENT    OF    PREPARALYTIC    STAGE.  267 

the  sick  should  be  buried  in  bed-coverings,  and  particularly 
heap  them  on  sick  children  to  their  torture  in  the  effort  to 
overcome  the  supposed  deadly  effect  of  a  draught.  I  am 
reminded  of  the  reply  made  to  the  frantic  question  of  a 
scandalized  spinster  whose  nurse  had  forcibly  removed  her 
bedgown  and  left  her  with  a  sheet  as  sole  covering  on  a 
scorching  August  day.  "Doctor,"  said  the  spinster,  ''won't 
1  catch  cold  like  this?"  "Catch  cold!"  said  the  sweating 
physician.  "Catch  cold!  My  dear  madam,  put  your  feet 
on  the  mantelpiece  and  enjoy  yourself!" 

MEDICATION. 

Elimination. — It  has  been  shown  that  poliomyelitis  at- 
tacks most  readily  those  persons  who  are  subject  to  con- 
stipation,  and  that  the  attack  is  limited  to  the  arrested  form 
of  the  disease  in  a  large  percentage  who  eliminate  the 
toxin  readily  with  a  diarrheal  discharge.  All  methods  for 
unloading  the  accumulated  waste  of  the  system  should  be 
promptly  employed  at  onset  of  poliomyelitis.  It  is  pos- 
sible that  this  eliminative  process  rids  the  system  imme- 
diately of  a  considerable  amount  of  the  toxin  whose  lesions 
have  been  observed  in  the  liver  tissues  and  intestinal 
lymphatics.  The  evacuation  of  residue  frees  the  system, 
permitting  absorption  of  water  and  the  prompt  effect  of 
medication. 

Elimination  may  be  freely  induced  by  the  use  of  gastric 
and  colonic  lavage,  cathartics,  and  diuretics.  The  use  of 
diaphoresis  and  diaphoretics  is  questionable,  and  is  not 
advocated  by  the  writer.  \Ye  do  not  as  yet  know  where 
we  stand  in  regard  to  the  vasomotor  system  in  this  disease. 
Sweating  is  a  profound  accompaniment  of  the  onset  in 
many  cases,  and  is  followed  by  extreme  prostration.  X«»t 
diaphoretics,  but  vasomotor  constrictors,  have  been  ad- 
vanced as  useful. 


268  INTAXT1LE    PARALYSIS. 

Colonic  lavage  should  be  prompt  and  thorough,  and 
repeated  daily  throughout  the  fever  stage. 

Calomel,  castor  oil,  and  magnesia  have  all  been  em- 
ployed in  the  initial  catharsis.  The  daily  use  of  citrated 
magnesia  or  uncombined  cascara  sagrada  will  tend  to  over- 
come the  paresis  of  the  bowels,  which  may  be  encountered 
for  a  considerable  period  of  time. 

Diuresis  should  be  promoted  during  the  fever  stage 
and  thereafter;  the  forced  feeding  of  water  alone  may 
overcome  the  paretic  retention  usually  observed.  The 
bladder  should  be  under  careful  observation.  Some  diffi- 
culty in  voiding  urine  is  present  in  even  mild  and  arrested 
cases.  Painful  retention  with  overflow  at  the  onset  of  this 
disease  has  been  mistaken  for  intussusception  and  operated 
(Lovett).  A  few  drops  of  sweet  spirit  of  niter  are  often 
effective  in  the  small  child.  The  immersion  bath  is  better. 
If  instrumentation  is  called  for,  it  is  well  to  use  a  mild 
internal  antiseptic  combined  with  a  mild  diuretic  and  the 
forced  feeding  of  water  during  the  period  in  which  cathe- 
terization  is  employed.  Xo  complicating  cystitis  has  fol- 
lowed the  usual  aseptic  instrumentation  when  the  formula 
below  was  in  use.  It  is  a  mild  internal  antiseptic  and 
diuretic  for  use  when  the  paretic  retention  of  poliomyelitis 
demands  instrumentation : — 

I£   Fluidext.  tritici  repentis ,",ij. 

Acicli   borici    .yj. 

Syrupi    .",  —  • 

Aquae  menth.  pip q.  s.  ad  ."jiv. 

M.     Sig. :     One  (i)  teaspoonful  in  water  every  four 

hours  for  adults ;   children  in  proportion. 

Strychnine. — There  is  perhaps  no  more  frequent  mis- 
take made  in  the  therapy  of  the  acute  stage  of  poliomyelitis 
than  the  use  of  physiologic  doses  of  strychnine  sulphate. 


TREATMENT    OF    PREPARALVTIC    STAGE.  269 

for  the  use  of  such  doses  is  in  this  case  the  addition  of  a 
detonator  to  a  high  explosive,  and  highly  destructive  in 
its  action. 

The  chief  physiologic  action  of  strychnine,  according  to 
the  United  States  Dispensatory,  is  stimulation  of  the  motor 
and  vasomotor  centers  of  the  cord.  It  is  cumulative  in 
action,  and  an  overdose  results  in  tonic  and  clonic  con- 
vulsions reflex  in  character  of  all  voluntary  muscles;  the 
body  is  rigid,  the  limbs  stiffly  extended,  and  the  chest  locked 
in  a  general  respiratory  spasm ;  death  occurs,  with  symp- 
toms of  asphyxia. 

The  above  description  is  a  fairly  accurate  picture  of  a 
severe  case  of  poliomyelitis,  and  strychnine  immediately 
augments  the  irritation  which  is  already  taking  place  in 
the  ganglionic  neuron.  It  has  been  a  common  thing  to 
load  a  child  up  with  hypodermics  of  strychnine  every  four 
hours  during  the  acute  stage  of  poliomyelitis.  Frauenthal 
has  seen  3  cases  of  children  with  strychnine  poisoning 
from  this  treatment,  and  considers  it  probable  that  some 
deaths  credited  to  infantile  paralysis  were  directly  caused 
by  cardiac  spasm  induced  by  overdosage  and  the  cumula- 
tive action  of  the  strychnine  prescribed.  The  exhibition  of 
strychnine  is  invariably  advocated  by  the  consultant  un- 
acquainted with  the  lesions  of  this  disease,  while  those 
authorities  who  have  had  the  most  extensive  opportunity 
of  observing  cases  during  the  acute  stage  of  the  disease 
are  unanimous  in  condemning  its  use  until  the  chronic 
stage  is  well  established. 

Bichloride  of  Mercury. — Hexamethylenamine  has 
completely  failed  to  arrest  the  inflammation  in  cord  and 
meninges,  although  it  has  been  thoroughly  tested  in  the 
\Yashington  epidemic.  There  is,  however,  a  remedy  of 
which  we  may  hope  that  further  trial  will  show  the  use. 
I  refer  to  mercury,  the  power  of  which  over  some  infec- 


270  INFANTILE    PARALYSIS. 

tions  has  become  better  realized  since  it  has  been  employed 
by  injection  into  the  muscles  or  veins. 

.-]  Case. — I  have,  however,  only  had  opportunity  to  test 
it  in  i  case  of  poliomyelitis  during-  the  acute  phase.  It  was 
done  because  of  a  sudden  advance  of  acute  ascending  paral- 
ysis in  an  adult  who  had  apparently  improved  on  the  pre- 
ceding day.  the  fifth  of  his  disease.  By  lumbar  puncture 
10  c.c.  of  cerebrospinal  fluid  were  withdrawn.  I  lead- 
ache  and  nausea  were  at  once  relieved,  and  the  paralysis 
ceased  to  progress,  while  the  temperature  fell  steadily. 
During  three  days,  five  doses  were  given  of  mercury 
bichloride  of  %  and  /4  gr.  alternately.  In  another  case 
of  the  same  kind  with  which  I  was  associated,  the  remedy 
was  not  tried,  and  the  disease  progressed  to  respiratory 
paralysis  and  death  on  the  fifth  day.  Both  these  cases  were 
adults  seen  in  consultation,  the  first  with  Dr.  John  Lewis. 
of  Bethesda,  Md. ;  the  second  with  Drs.  A.  B.  Hooe  and 
Roy,  of  Washington.  It  is  true  that  the  injections  would 
greatly  perturb  a  child  who  is  hyperexcitable  from  menin- 
gitis; but  a  temporary  disturbance  is  preferable  to  paralysis 
or  death,  and  much  less  pain  is  produced  by  the  small 
needle  used  than  by  the  injection-syringe  needle  required 
when  diphtheria  or  meningococcus  diseases  are  in  question. 
If  the  disease  is  protozoa!,  the  rationale  of  mercury  is 
evident.  (Williams,  of  Washington.) 

Count  erirritation. — Any  method  of  counterirritation  is 
contraindicated  in  poliomyelitis.-  Cauterization  of  the 
spine,  and  the  application  of  mustard  plasters,  or  fly- 
blisters,  are  methods  especially  pernicious  during  the  acute 
stage,  for  at  this  period  they  augment  the  pain  and  render 
possible  the  formation  of  bed-sores.  Death  from  sepsi^ 
followed  the  application  of  the  medicated  ( ?)  spinal  plaster 
used  by  a  notorious  faker  of  the  West. 


TREATMENT  OF  PREPARALYT1C  STAGE.       271 

Vasoinotor  Control,  Local  Depletion,  and  Rcsorption. 
— Application  of  the  d'Arsonval  high-frequency  current 
to  the  spine  during  the  acute  stage  of  poliomyelitis  is  used 
and  recommended  by  Dr.  Henry  Frauenthal  at  the  Xcw 
York  Hospital  for  Deformities.  Observing  that  the  pri- 
mary effect  of  the  application  of  the  high-frequency  current 
in  obliterating  endarteritis  was  a  blanching  of  the  skin 
which  continued  for  several  moments,  the  current  was 
applied  to  the  spine  in  the  treatment  of  the  early  stage, 
with,  in  i  case,  inhibition  of  further  advance  of  a  progress- 
ive paralysis  and  rapid  and  complete  regression.  The 
d'Arsonval  current  in  the  hands  of  Arrhenius,  of  Stock- 
holm, has  recently  been  shown  to  exert  an  extraordinary 
stimulus  to  the  metabolism  of  the  living  cell.  The  oscillat- 
ing current  may  have  a  rate  of  alternation  of  millions  a 
second.  The  molecular  action  on  the  body  tissues,  which 
are  about  nine-tenths  water,  is  only  surmised  as  yet.  An 
agent  which  may  produce  local  depletion  cannot  be  over- 
looked until  a  specific  for  poliomyelitis  has  been  discovered. 
The  contraindication  for  the  use  of  the-  high-frequency 
current  is  the  augmentation  of  stimulation  to  the  ganglion 
cells.  A  method  of  local  depletion  used  with  excellent  effect 
in  acute  otitis  media  I  have  not  seen  advocated  in  polio- 
myelitis, but  believe  it  well  worth  a  trial.  When  Pasteur 
was  attacked  by  the  acute  spinal  paralysis  which  I  have 
elsewhere  shown  to  be  an  attack  of  poliomyelitis,  his 
astonished  and  bewildered  consultants  applied  sixteen 
leeches  to  the  occipital  and  cervical  region,  believing  they 
dealt  with  cerebral  hemorrhage.  In  the  treatment  of  an 
ascending  paralysis,  succeeding  the  establishment  of  thor- 
ough elimination,  I  should  now  endeavor  to  obtain  local 
depletion  and  the  determination  of  fresh  blood  to  the  cervi- 
cal and  upper  dorsal  region,  by  the  application  of  several 
leeches. 


272  IXFAXT1LE    PARALYSIS. 

Ergot  and  Gclscniimii. — The  use  of  ergot  and  gelse- 
miuiii  is  advocated  in  poliomyelitis,  to  lessen  the  supply  of 
blood  to  the  congested  area  of  the  cord.  Ergot,  which  was 
formerly  said  to  have  a  selective  action  on  congested  pul- 
monary vessels  and  was  used  to  abort  pneumonia,  is  now 
called  on  to  exert  a  similar  selective  action  on  the  vascular 
supply  of  cord  and  brain.  If  such  local  action  could  be 
obtained  it  would  be  undesirable.  It  is  not  a  lessening  of 
the  blood-supply  that  is  needed,  but  more  blood:  fresh, 
pure,  and  regenerating.  The  study  of  a  section  from  the 
lumbar  level  of  the  cord  of  an  acute  case  of  poliomyelitis 
is  convincing  in  this  respect.  The  cut  ends  of  the  vessels 
are  not  distended ;  they  are  choked  with  a  collar  of  round 
cells;  their  walls  have  been  rendered  permeable;  hyper- 
•  •sinosis  is  taking  place;  the  walls  are  leaking  at  every 
joint.  It  is  not  desirable  to  cut  off  the  supply  of  blood, 
but  to  augment  it  with  a  fresh  and  toxin-minus  supply. 

"Ergot,  I  believe,  is  contraindicated.  I  can  see  no  reason  why 
a  drug  which  contracts  the  smaller  arteries  should  be  given  in  a 
condition  in  which  the  blood-supply  of  nervous  centers  is  already 
diminished  by  a  too  small  caliber  of  the  smaller  vessels."  (Skoog. ) 

Antipyretics. — The  temperature  of  poliomyelitis  is  a 
measure  of  the  struggle  of  the  organism  against  the  toxin. 
It  is  best  alleviated  by  hydrotherapy,  external  and  in- 
ternal. The  forced  feeding  of  water,  colonic  flushings, 
sponge  baths,  immersion  baths  when  possible,  and  the  ice- 
bag  are  all  efficient  aids.  The  temperature  will  not  fall 
when  the  bowels  are  finally  moved  during  the  onset  of  the 
case,  unless  paralysis  is  impending,  or  the  case  is  happily 
merging  into  the  arrested  type.  Hydrotherapy  will  lower 
the  temperature  only  temporarily  until  the  fall  by  crisis 
which  precedes  the  paralysis.  Nevertheless,  the  measures 
relieve  and  benefit.  The  parents  may  request  you  to  break 
the  fever;  they  may  have  been  told  by  an  unscrupulous 


TREATMENT    OF    PREPARALYTIC    STAGE.  273 

confrere  that  the  fever  should  be  broken.  Explain  to  them 
that  any  drug  sufficiently  depressant  to  the  heart's  action 
to  lower  the  temperature  of  the  child  at  this  stage  will 
weaken  the  heart  and  lessen  the  chances  for  life  and  a 
fortunate  issue. 

Sedatives  and  Analgesics. — The  foregoing  remarks 
about  antipyretic  drugs  during  the  acute  stage  of  poliomye- 
litis apply  equally  well  to  the  administration  of  salicylates: 
they  are  equally  depressing  in  effect,  and  their  exhibition 
in  these  cases  I  consider  dangerous.  Bromides,  in  addi- 
tion to  their  depressant  action,  are  irritant  to  the  stomach, 
which  should  be  humored  into  retaining  as  much  nourish- 
ment as  possible.  \Yith  extreme  restlessness,  or  pain,  or 
both,  codeine  is  the  most  soothing  and  least  harmful  drug 
which  we  have  for  these  cases.  Morphine,  or  other  prepa- 
rations of  opium,  may  be  used  -with  great  caution  as 
rectal  suppositories,  remembering  that  their  use  may 
undo  all  you  have  striven  to  attain,  by  again  checking 
elimination. 

Internal  Antiseptics. — The  internal  administration  of 
some  preparation  of  formalin  has  been  advocated  during 
the  acute  stage  of  poliomyelitis,  and  its  usefulness  would 
seem  to  be  demonstrated  by  the  fact  that  the  presence  of 
hexamethvlenamine  has  been  demonstrated  in  the  spinal 
fluid  <>f  monkeys  one-half  hour  after  administration.  The 
liberated  drug  is  said  to  have  an  inhibitory  effect  on  the 
toxin  in  the  cord,  and  we  must  therefore  examine  its 
advantages  and  disadvantages,  to  make  use  of  or  have 
excellent  reasons  for  discarding  such  a  powerful  medic- 
ament. 

Before  summarizing  the  advantages  and  disadvantages 
attending  the  use  of  the  many  mercantile  preparations  of 
this  drug,  we  may  consider  the  statements  of  physicians 
making  use  of  this  drug:— 


u 


274  INFANTILE    PARALYSIS. 

Hexamethylenamine  (urotropin)  may  have  some  effect  in  dis- 
infecting the  spinal  fluid,  but  if  long  continued  there  is  a  possibility 
that  the  formalin  set  free  may  have  a  hardening  effect  upon  the 
^pinal  cord.  Two  grains  may  be  given  every  two  hours  during 
the  first  two  or  three  days.  ( \Yin.  Spiller,  Professor  of  Neuro- 
pathology  and  Associate  Professor  of  Neurology  in  the  University 
of  Pennsylvania,  "Diagnosis  and  Medical  Treatment  of  Poliomye- 
litis," Pennsylvania  Medical  Journal,  Dec.,  1911.) 

I'rotropin  was  sometimes  given  and  with  uncertain  results. 
(Anderson,  Nebraska,  "Epidemic  of  279  Cases  of  Poliomyelitis," 
Pediatrics,  August,  1910.) 

Urotropin  should  be  given  in  full  doses  well  diluted  and  kept 
up  for  quite  a  while,  but  watch  out  for  irritation  in  the  urinary 
tract.  (Marvin,  Discussion  of  paper.  "Infantile  Paralysis."  by 
Thompson,  Kentucky,  Louisville  Monthly  Journal,  April.  1912.) 

It  therefore  seems  a  logical  remedy  (hexamethylenamine)  in 
acute  poliomyelitis,  the  dose  to  be  from  5  to  15  grains  every  three 
hours  according  to  the  age  of  the  patient,  the  medication  to  be 
instituted  at  the  earliest  possible  moment.  (Bierring,  "Acute  Polio- 
myelitis in  Iowa,"  Interstate  Medical  Journal,. Jan.,  1912.) 

While  there  is  no  proof  as  yet  that  this  drug  (urotropin)  has 
any  effect  in  modifying  the  course  of  the  disease,  its  use  is  free  from 
any  valid  objection  and  is  quite  generally  recommended.  (Frost, 
United  States  Public  Health  Service  Bulletin,  No.  44.) 

Fullerton  reports  a  case  of  medicinal  cystitis  following  its  use 
with  painful,  burning,  frequent  urination,  hematuria,  and  the  pass- 
ing of  many  small  blood-clots  as  well  as  pieces  of  bladder-membrane 
several  centimeters  square.  For  two  nights  and  three  days  after  the 
onset  of  the  hematuria  the  patient  continued  to  pass  blood-clots  and 
bladder-membrane.  The  urine  was  demonstrated  to  be  sterile ;  the 
>ynipi<>ms  arose  after  the  drug  was  begun,  and  cleared  up  at  once, 
though  gradually,  after  it  was  discontinued,  and.  there  being  no 
other  possible  etiologic  factor,  all  this  seems  to  be  conclusive 
evidence  that  this  was  a  medicinal  cystitis. 

It  has  also  been  reported  that  the  injection  of  hexa- 
methylenamine in  guinea-pigs  produced  congestion  and 
hemorrhages  into  the  stomach. 

Is  the  mucous  membrane  of  a  child's  stomach  more 
resistant  than  that  of  a  guinea-pig?  Is  the  delicate  vascu- 


TREATMENT    OF    PREPARALYT1C    STAGE.  275 

lar  lining  of  a  child's  bladder  less  susceptible  than  that  of 
a  woman  of  25  years  of  age?  Are  we  to  empirically 
liberate  in  the  spinal  canal  a  solution-  known  to  have  a 
hardening  effect  on  living  tissue-cells?  In  poliomyelitis, 
with  a  destructive  toxin  already  at  work,  are  we  justified 
in  introducing  a  killing  and  fixing  agent  into  the  spinal 
canal?  If  the  drug  is  not  liberated,  is  the  medication  of 
value  ?  These  are  questions  every  practitioner  should  con- 
sider before  making  use  of  the  various  preparations  of 
formalin  that  are  at  present  advocated  for  poliomyelitis  in 
children. 

The  use  of  hexamethylenetetramine  in  poliomyelitis  was 
first  advocated,  if  I  am  not  mistaken,  by  Preble,  of  Chicago, 
"in  view  of  our  desperate  helplessness,"  in  a  letter  to  the 
Journal  of  the  American  Medical  Association.  Those  who 
advocate  its  use  today  claim  hexamethylenamine  (a)  will 
break  down  and  liberate  free  formalin  in  the  tissues.  ( b  ) 
If  given  by  mouth  will  remain  in  blood,  bile,  and  gall- 
bladder for  twenty-four  hours,  (c)  If  the  dose  is  so 
much  as  75  grains  per  day,  it  will  prevent  bacterial  growth 
in  these  passages  (Crow),  (d)  It  may  remain  unchanged 
on  excretion,  only  liberating  formaldehyde  after  more  or 
less  stagnation,  (r)  It  is  excreted  in  the  urine  unchanged, 
and  breaks  down  after  remaining  in  the  bladder  at  least 
one  and  a  half  hours.  (/)  It  is  recommended  in  geni- 
tourinary affections  when  catheterization  has  to  be  re- 
sorted to  for  any  length  of  time,  (g)'  Free  formalin  has 
been  demonstrated  in  the  spinal  fluid  of  apes  one-half  hour 
after  administration. 

Dosage  and  Administration. — Spiller  prescribes  2 
grains  of  urotropin  every  two  hours  for  two  or  three  days 
only.  I  have  seen  no  report  which  justifies  the  use  of  a 
larger  dosage  for  children.  The  drug  is  administered 
after  solution  in  a  large  amount  of  water,  and  is  said  by 


276  INFANTILE   PARALYSIS. 

Ager,  of  Brooklyn,  to  be  less  irritant  when  accompanied 
by  Vichy  or  bicarbonate  of  soda. 

Quinine. — Hughes,  of  St.  Louis,  advocates  a  vigorous 
course  of  quinine  in  poliomyelitis.  Quinine  sulphate  is  a 
powerful  internal  antiseptic  and  well  tolerated  by  the 
economy.  The  blood  during  the  acute  stage  of  polio- 
myelitis is  known  to  be  infective.  Lacking  a  specific  treat- 
ment in  poliomyelitis,  the  use  of  quinine,  while  empiric,  is 
justifiable. 

Echinacea. — The  exhibition  of  echinacea  during  the 
acute  stage  of  poliomyelitis  is  advocated  by  Frauenthal. 
who  considers  it  to  be  the  best  of  internal  and  local  anti- 
septic. The  dosage  is  5  minims  to  I  dram  of  the  tincture 
of  echinacea  every  six  hours.  Locally  it  may  be  applied 
in  full  strength  or  diluted  in  1,2  or  3  parts  of  water. 

Lumbar  Puncture  During  Acute  Stage  of  Poliomye- 
litis.— There  are  three  methods  by  which  pressure  may  be 
reduced  and  toxicity  lessened  during  the  acute  stage  of 
poliomyelitis : — 

1.  Elimination  (previously  outlined). 

2.  Dilution  and  lowering  of  specific  gravity  of  blood 
(previously  outlined). 

3.  Lumbar  puncture. 

A  quantitative  increase  in  the  cerebrospinal  fluid  is  con- 
stant during  the  acute  onset  of  poliomyelitis,  and  is  evi- 
denced by  a  plus  pressure  or  the  actual  spurting  of  the 
spinal  fluid  on  lumbar  puncture,  as  well  as  bulging  of  the 
fontanels,  and  Macewen's  sign. 

The  cerebrospinal  fluid  drawn  during  the  acute  stage 
has  been  proven  infectious.  Theoretically  it  would  seem 
the  abstraction  of  an  amount  of  this  fluid  would  relieve 
tension  and  remove  toxic  material.  The  majority  of  recent 
reports  on  lumbar  puncture  during  the  acute  stage  of  polio- 
myelitis, whether  the  tapping  was  done  for  diagnosis  or 


TREATMENT    OF    PREPARALYT1C    STAGE.  777 

treatment,  indicate  that  the  method  is  of  therapeutic  value. 
Lumbar  puncture  is  also  a  valuable  and  only  certain  method 
of  diagnosis  of  the  disease  during  onset,"  and  of  prognosis 
as  to  the  progression  and  regression  of  the  paralysis. 

Routine  Method  of  Lumbar  Puncture  of  Xcw  York 
Health  Department. — Patient  in  left  lateral  position  with 
flexed  spine.  Paint  cutaneous  area  over  lumbar  spines 
with  tincture  of  iodine.  Freeze  surface  with  ethyl  chloride 
spray.  Puncture  in  median  line  between  fourth  and  fifth 
lumbar  spine. 

The  possibility  of  a  needle  breaking  during  lumbar 
puncture  may  be  averted  by  the  use  of  a  simple  apparatus 
devised  by  Lorenz,  of  Wisconsin.  A  light  padded  stick 
placed  beneath  the  knees,  and  attached  by  means  of  light 
straps  to  canvas  bands  crossing  the  shoulder  and  beneath 
the  armpit,  and  drawn  close,  will  secure  the  flexion  desired 
and  prevent  sudden  extension. 

Objections  to  the  use  of  lumbar  puncture  are  the  pos- 
sibility of  (a)  sudden  death;  (b)  infection;  (c)  the  break- 
ing of  a  needle,  previously  noted;  (rf)  friends  of  patient 
attributing  paralysis  to  puncture;  (e)  hemorrhage  from 
puncture  of  a  vessel  of  the  pia-arachnoid. 

Hansen,  of  Christiania,  has  recently  collected  reports 
of  30  deaths  following  lumbar  puncture.  As  lumbar  punc- 
ture has  been  in  quite  general  use  since  the  introduction 
of  spinal  anesthesia  in  1899,  the  total  percentage  of  fatali- 
ties must  be  very  low. 

The  danger  from  infection  might  increase  with  re- 
peated punctures  with  a  lessening  of  surgical  technique. 

The  patient's  friends  should  be  notified,  before  the  pro- 
cedure, that  paralysis  is  looked  for,  which  the  puncture 
may  avert ;  they  will  otherwise,  if  ignorant,  almost  cer- 
tainly attribute  the  paralysis  to  the  treatment. 

Shidler,  of  Nebraska,  reports  that  in  2  cases  of  the 


278  1XFAXT1LE   PARALYSIS. 

neuritic  type  unrelieved  by  large  closes  of  opiates  the  pain 
was  lessened  by  lumbar  puncture. 

Spiller  advocates  lumbar  puncture  for  the  relief  of  the 
intractable  pain,  stating  that  he  has  known  lumbar  punc- 
ture to  give  great  relief  under  such  circumstances. 

Serologic  Treatment. — The  serum  treatment  of  polio- 
myelitis is  still  in  the  experimental  stage.  Drs.  Anderson 
and  Frost  demonstrated  a  serologic  neutralization  test  of 
much  value  in  the  determination  of  cases  of  the  arrested 
(abortive)  type.  Serologic  immunization  of  monkeys 
offers  hope  that  human  immunity  may  yet  be  artificially 
obtained.  There  is  at  present  no  antitoxin  for  polio- 
myelitis. 

Diet. — The  diet  should  be  restricted,  nutritious,  and 
easily  digestible.  All  fruits  should  be  cooked,  and  n<  > 
seeded  berries,  etc.,  given,  to  clog  and  irritate  a  paretic 
digestive  tube.  During  the  fever  stage  a  child  will  take 
ices  and  iced  drinks  freely.  Fruit  juices  and  ices  should 
be  left  pleasantly  acid.  Lemonade,  orangeade,  pineapple- 
ade,  and  the  same  ices  are  acceptable. 

If  the  patient  is  not  fond  of  milk,  it  may  be  rendered 
very  attractive  when  served  as  one  of  many  cream  soups  or 
broths.  Corn  soup,  which  consists  of  milk  heated  with 
canned  corn,  or  freshly  popped  popcorn  strained  and 
seasoned,  is  a  dish  that  many  children  who  dislike  milk 
will  take  eagerly.  Croutons  or  educator  crackers  add  to  the 
nutritive  values.  Fresh  chicken  broth,  with  or  without  the 
addition  of  rich  milk,  served  with  soda  crackers  or  toasi. 
is  much  relished.  Milk  toast,  a  dish  consisting  of  a  plate 
of  fresh  and  fragrant  toast,  and  a  pitcher  of  scalding, 
creamy  milk,  to  be  poured  over  the  toast  slice  by  slice  at 
the  bedside,  where  the  child  may  inhale  and  be  tempted  by 
the  appetizing  aroma  of  both,  is  a  much  more  nutritious 
dish  than  the  sodden  mass  of  charred  bread  and  white 


TREATMENT    OF    PREPARALYTIC    STAGE.  279 

sauce  frequently  presented  the  sick.  Oyster  soup,  clam 
broth,  and,  where  it  can  be  obtained,  coquina  broth  are  all 
appetizing'  and  nutritive  dishes. 

All  of  the  cooked  breakfast  foods  may  be  used  as  such, 
or,  slightly  sweetened,  molded  and  served  cold  with  cream. 
Rice  is  of  value.  The  package  rice  is  a  larger,  cleaner 
kernel  than  ordinary  bulk  rice.  It  should  be  washed 
through  numerous  waters,  and  cooked  in  boiling  water 
until  tender,  then  drained  and  steamed  till  each  kernel 
is  a  separate  entity.  Served  with  a  separate  dish  of  steamed 
dates  and  rich  milk,  the  food  values  are  in  perfect  com- 
bination. 

Many  of  these  children  will  have  to  be  fed.  When  the 
arms  are  affected  it  is  usually  the  right  arm  that  is  para- 
lyzed. When  the  legs  only  are  affected  the  child  from  pain 
or  prostration  may  leave  the  food  uneaten.  The  feeding 
>h«  mid  be  unhurried.  When  there  is  difficulty  in  drinking, 
it  may  take  considerable  ingenuity  to  bend  a  glass  tube  at 
just  the  right  angle  to  reach  from  the  child's  mouth  to  a 
glass  arranged  just  below  the  pillow,  but  it  can  be  done, 
and  the  reward  comes  in  seeing  the  child  gradually  absorb 
glass  after  glass  of  the  water,  etc.,  with  no  extra  exertion. 

In  paralysis  of  the  pharyngeal  muscles  it  may  be  neces- 
sary t(  >  resort  to  stomach  feeding.  Regurgitation  of  liquids 
through  the  nose  indicates  some  beginning  paresis. 

TREATMENT  OF  PROGRESSIVE  ASCENDING  OR  DE- 
SCENDING PARALYSIS  WITH  IMPENDING 
PARALYSIS   OF  RESPIRATION. 

I.  Remove  patient  to  outdoor  air.    Porch;  tent;  roof. 
1 1 .   Use  pulmotor. 

I  IT.  Use  Sylvester  method  of  artificial  respiration. 
(  XOTK. — A    satisfactory   pulmotor    has   been    devised 
from  a  vacuum  cleaner.     Langhorst,  Elmhurst,  Illinois.) 


CHAPTER   XII. 
Hydrotherapy  in  Infantile  Paralysis. 

THE  value  of  hydrotherapy  in  poliomyelitis,  in  conjunc- 
tion with  other  forms  of  treatment  herein  described,  com- 
pels serious  consideration.  \Ye  regard  such  measures  as  a 
part  of  the  remedial  armamentarium  from  the  onset  of  the 
disease. 

Fever  is  one  constant  symptom  of  onset  of  the  acute 
attack.  It  varies  from  an  elevation  of  100°  to  103°  F.,  and 
the  initial  rise  probably  averages  104°  to  105°  F. 

Cold  sponging,  augmented  by  the  application  of  a  cold 
pack  to  the  spinal  column,  may  be  used  to  allay  the  moderate 
fever.  With  a  more  marked  elevation  of  temperature  and 
especially  with  those  cases  occurring  during  the  extreme 
heated  period  of  summer,  the  immersion  bath  should  be 
used.  That  many  such  cases  instinctively  seek  the  immer- 
sion bath  is  evidenced  by  the  number  of  histories  of  cases 
who  have  been  in  swimming  a  few  hours  preceding  the 
appearance  of  the  paralysis.  When  the  preparalytic  tem- 
perature remains  continuously  at  a  considerable  elevation, 
105°  or  above,  it  is  well  to  employ  the  continuous  sus- 
pension bath  until  such  time  as  the  fever  gives  indica- 
tion of  terminating  by  crisis.  This  continuous  bath  was 
also  instinctively  sought  by  the  12-year-old  patient  of  Dr. 
Marquardt's,  who  crawled  under  the  garden -hose  while  in 
the  acute  stage  and  was  found  there  some  hours  later. 

The  cool  immersion  bath  aids  in  controlling  tempera- 
ture by  the  abstraction  and  diffusion  of  heat,  and  thus 
assists  and  renews  the  body  tissues  in  their  warfare  against 
the  destructive  virus. 

The  bath  also  relieves,  pain  in  some  degree  and  may 
banish  it  temporarily  by  providing  a  buoyant  supporting 
(280) 


HYDROTHERAPY    IX    IXFAXTILE    PARALYSIS.  281 

medium  which  equalizes  and  distributes  pressure,  this  relief 
conducing  to  at  least  brief  relaxation  and  rest. 

Other  hydrotherapeutic  measures  of  great  value  during 
the  onset  of  poliomyelitis  relate  to  the  forced  feeding  of 
water,  the  use  of  repeated  colonic  lavage,  and  the  applica- 
tion of  ice  to  the  spinal  column ;  these  measures  are  given 
in  detail  in  the  chapter  on  the  Treatment  of  the  Pre- 
paralytic  Stage. 

The  agonizing  hyperesthesias  present  necessitate  the 
intelligent,  steady,  and  firm  handling  of  these  patients 
during  the  administration  of  pack  or  bath.  The  most 
painful  area  is  the  spastic  neck  and  spine,  while  the  muscles 
of  the  buttocks  and  hip  of  the  leg  which  will  later  become 
paretic  are  frequently  as  tender  as  the  area  about  an  ab- 
scess. Avoid  flexing  the  head  on  the  chest,  the  leg  on  the 
thigh,  or  the  thigh  on  the  abdomen;  use  most  care  in  not 
antagonizing  the  rigid  spine  to  the  great  agony  of  the 
patient  by  attempting  to  lift  or  carry  in  the  usual  manner 
with  one  arm  under  the  shoulders  and  one  under  the 
knees. 

A  portable  bathtub,  drawrn  to  the  bedside,  and  a  bed 
lift  with  pulley  and  tackle,  with  a  rigid  framework  on 
which  the  patient  reclines,  supply  the  best  means  of  trans- 
portation between  bed  and  bath.  The  young  patient  should 
not  be  left  unattended  in  the  bath  for  a  single  moment  of 
time,  and  as  several  other  matters  must  be  arranged  during 
this  brief  period,  such  as  maintaining  the  temperature  of 
the  water  at  a  uniform  heat,  it  is  desirable  to  have  an 
assistant  during  the  bath  period. 

"With  the  approach  of  the  paralysis  the  fever  declines 
by  crisis  and  the  body  temperature  frequently  becomes 
subnormal,  while  the  paralyzed  extremity  becomes  flaccid, 
cold,  and  clammy. 

At  this  period  the  immersion  bath  should  be  given  at 


282  1XFANT1LE    PARALYSIS. 

a  temperature  of  iooc  to  103  F.,  beginning  each  bath  at 
the  former  temperature  and  gradually  raising  the  water's 
warmth  several  degrees.  The  pain,  which  is  still  present 
in  this  stage,  is  very  amenable  to  heat  applied  by  means  of 
hot-water  bags,  the  electric  pad,  the  hot  sand-bag,  etc. ; 
but  the  most  immediate  relief  with  subsequent  rest  is 
found  in  the  use  of  the  hot  immersion  bath.  Fifteen 
minutes  are  sufficient  to  allow  for  the  bath,  after  which  the 
child  should  be  lifted  out  on  a  dry  blanket  and  the  drying 
of  body  done  in  bed.  The  temperature  of  the  room  should 
prohibit  any  postlavage  chilling. 

The  most  important  function  of  the  bath  during  this  and 
the  succeeding  chronic  stage  of  infantile  paralysis  is  no 
doubt  overlooked.  I  wish  to  call  attention  to  it  with  some 
emphasis.  When  the  paralyzed  limb  is  lowered  into  the 
water  for  some  minutes  the  surface  of  the  limb  becomes 
accustomed  to  the  water  pressure,  which  is  sixty-two  and  a 
half  pounds  to  the  square  inch;  after  removal  from  the 
water  into  the  atmospheric  pressure,  which  is  fifteen 
pounds  to  the  square  inch,  the  change  in  pressure  result ^ 
in  a  type  of  hyperemia  that  continues  to  act  for  some  time. 
The  nutritional  value  of  this  hyperemia  when  regularly 
induced  will  tend  to  counteract  the  trophic  loss  of  the 
lesion.  I  consider  it  to  be  of  great  value  in  conserving  the 
nutrition  not  only  of  the  superficial  muscular  tissue,  but 
with  a  possible  tonus  for  the  proliferating  osseous  tissues. 

As  soon  as  pain  has  ceased  to  be  a  constant  factor  in 
the  paralyzed  extremities,  the  attendant  may  begin  passive 
movements.  These  movements  are  most  easily  undertaken 
while  the  child  is  immersed  in  water  of  a  temperature  to 
slightly  relax  and  sooth  all  hyperesthesias,  and  when  the 
child's  confidence  has  been  established  they  may  be  con- 
tinued when  out  of  the  bath.  Valuable  when  the  limb  can- 
not be  manipulated  by  the  little  patient,  they  are  yet  not  to 


HYDKOTHERAPY    IN    INFANTILE    PARALYSIS.  283 

be  compared  in  value  with  active  movement  spontaneously 
produced  by  the  child  himself. 

\\ "ith  the  increased  ease  of  movement  which  comes 
from  suspension  in  water,  the  child  should  be  induced  to 
make  free  active  movements;  this  is  perhaps  most  easily 
effected  with  games  connected  with  the  delightful  ex- 
panding and  floating  toys  devised  by  the  Japanese.  An 
aquarium  one  day,  a  floating  garden  the  next,  and  some 
ingenuity  combined  with  much  intelligence  on  the  part  of 
the  attendant  will  be  rewarded  with  the  utilization  of  all 
ttninvolved  musculature.  Amusement  should  never  be  al- 
lowed to  grow  trite,  nor  the  bath  continued  above  one-half 
hour.  Kicking  and  splashing  should  be  encouraged,  with 
constant  supervision  that  disabled  cervical  muscles  do  not 
allow  sagging  of  the  head  to  the  water  line.  Tact  must 
terminate  the  bath  in  a  happy  manner  that  will  avert  dis- 
turbance. 

WARM-WATER   BATH    FOR   PARALYTIC  LIMB 
AT  BEDTIME. 

The  circulation  of  the  paralytic  extremity  is  always 
impaired  and  the  child  suffers  from  cold.  The  limb  will  be 
found  to  have  a  surface  temperature  several  degrees  below 
that  of  its  fellow*.  A  warm-water  bath  at  bedtime,  during 
which  the  limb  is  immersed  in  water  between  100°  and 
1 10°  for  twenty  minutes,  will  stimulate  the  circulation  and 
the  member  will  be  found  to  remain  warm  for  a  number 
of  hours  thereafter.  This  treatment,  while  adding  greatly 
to  the  comfort  of  the  patient,  brings .  about  an  actual 
trophic  change  which  stimulates  growrth  in  the  tissues  and 
bony  structures. 

The  addition  of  sea-salt  to  the  w'ater  of  the  bath  will 
find  favor  with  parents,  and  as  the  addition  renders  the 
water  slightly  more  buoyant  there  may  be  some  slight 


284  INFANTILE    PARALYSIS. 

value  in  its  use.  The  daily  bath  should  be  followed  by  a 
nap,  and  on  sunny  days  by  a  sun  bath.  The  sun  bath 
should  be  given  by  direct  exposure  of  the  body  to  the  sun's 
nn>:  with  summer  heat  this  can  be  easily  attained;  later 
in  the  season  a  sunny  window  and  heating  plant  are  neces- 
sary paraphernalia  of  the  sun  bath.  Protect  the  eyes  if 
there  is  any  complicating  photophobia. 

Guard  against  chilling  after  the  bath.  The  paralyzed 
limb  may  be  wrapped  in  soft  flannel :  an  electric  pad  will 
be  found  a  desirable  permanent  occupant  of  the  side  of  the 
bed,  and  will  prevent  continual  refilling  of  hot-water 
bottles,  with  possibility  of  a  spill. 

The  child  should  never  be  left  alone  for  one  instant  in 
the  bath,  for  fear  of  drowning.  The  sun  bath  may  be 
replaced  by  dry  heat,  baking  the  extremity  in  hot  air,  etc. 


CHAPTER   XIII. 

Electrotherapy. 

THE  therapeutic  use  of  electricity  has  already  as  wide 
a  range  as  the  therapy  of  water,  and  the  degree  of  utiliza- 
tion of  these  great  agents  varies  directly  with  the  period  of 
time  which  has  elapsed  since  the  date  of  discovery  of  their 
usefulness.  The  human  race  for  untold  centuries  has  been 
acquainting  itself  with  the  therapeutic  values  of  visible  and 
palpable  water.  The  far  more  powerful  agent,  electricity, 
unrecognized  because  unseen  and  unfelt,  has  only  recently 
been  harnessed  to  the  uses  of  humanity,  who  now  begin  to 
perceive  the  energy,  the  initiative  to  cell  growth,  the  in- 
hibition of  destructive  tissue  change,  the  vital  heat,  and 
the  remedial  light  to  be  derived  from  it.  \Ye  know  that  90 
per  cent,  of  the  body  tissues  are  composed  of  water,  but  are 
unaware  of  the  proportionate  values  of  energy,  initiative, 
temperature,  and  cell  growth,  and  their  possible  main- 
tenance by  somatic  electric  manufacture,  storage,  and  dis- 
charge. 

The  methods  of  electric  treatment  of  the  acute  and 
chronic  stages  of  poliomyelitis  differ  absolutely  as  to  the 
conditions  encountered,  the  results  to  be  achieved,  and  the 
form  of  electricity  to  be  employed.  The  physician  may  call 
tn  his  aid  the  high-frequency  current,  the  static  machine, 
the  X-ray,  the  galvanic  and  faradic  currents  separate  or  in 
combination,  or  the  concentrated  sunshine  of  the  leuco- 
descent  lamp.  By  these  various  agents  he  may  successfully 
relieve  pain,  produce  resorption.  stimulate  vasomotor  con- 

(285) 


286 


INTAXTILK    PARALYSIS. 


traction,   maintain   muscular   tonus,   promote  cell   metab- 
olism, and  stimulate  defective  growth. 

Electric  energy  is  regarded  as  life,  and  considered  to 


Fig.  71.— Total  regressive  paralysis  of  all  four  extremities,  with 
atrophy  and  normal  function.  No  early  treatment.  (X.  Y.  Hospital 
for  Deformities  and  Joint  Diseases.) 

be  the  hidden  force  that  actuates  cell  vitality,  by  many  <>f 
those  investigators  whose  research  best  qualify  them  to 
speak  of  its  manifold  modes  of  power  and  expression. 

While  the  blood-vessels  of  the  spinal  cord  are  the  pri- 


ELECTROTHERAPY. 


287 


mary  point  of  attack  of  the  toxic  virus  of  poliomyelitis,  the 
inflammatory  processes  rapidly  involve  the  meninges,  the 
gray  motor  and  the  white  conduction  tracts,  all  nerve-ele- 
ments being  successively  reduced  by  pressure  or  starvation 
to  a  state  of  extreme  irritability,  suspended  animation,  or 
necrosis  with  the  formation  of  scar  tissue. 


Fig.  72. — Total  regressive  paralysis  of  all  four  extremities  with 
treatment  initiated  during  acute  stage.  Perfect  function,  no  atrophy. 
(X.  V.  Hospital  for  Deformities  and  Joint  Diseases.) 

\Yhile  motor  paralysis  is  the  more  dramatic  effect  of 
the  lesions,  the  augmentation  of  the  pain  sense,  the  impair- 
ment of  tactile  and  temperature  sense,  the  implication  of 
the  co-ordinating  centers,  and  the  retardation  in  develop- 
mental processes,  when  overlooked  or  ignored,  are  respon- 

for  manv  failures  in  treatment. 


288  INFANTILE    PARALYSIS. 

In  consideration  of  the  motor  paralysis  it  was  well 
said : — 

Treatment  directed  solely  to  mechanical  ends — whether  by  cor- 
recting deformities  or  strengthening  individual  muscles — cannot  of 
itself  suffice  for  the  requirements  of  all  cases. 

i.  The  (palsied)  limb  may  be  considerably  smaller  than  it.- 
fellow  without  much  impairment  of  its  motor  function. 

2..  With  severe  palsy  the  limb  may  nevertheless  remain  of 
normal  length,  keeping  pace  with  the  sound  side. 

3.  In  the  case  of  a  diseased  upper  segment — say,  a  thigh — the 
lower  segment  (leg)  may  grow  longer  than  the  corresponding  por- 
tion of  the  undamaged  limb. 

In  electricity  we  have  the  only  agent  capable  of  Stimulating 
defective  growth;  this  fact  alone  places  those  who  use  it  with  skill 
in  a  position  of  peculiar  strength.  (Hernaman-Johnson,  British 
Jour.  Children's  Dis.,  December,  1911.) 

HIGH-FREQUENCY  CURRENT  DURING 
ACUTE  STAGE. 

Application  of  the  high-frequency  current  to  the  cutane- 
ous surfaces  of  the  spinal  column  is  recommended  at  the 
earliest  moment  after  motor  inco-ordination,  or  other  signs 
or  symptoms,  confirm  a  suspected  diagnosis  of  the  onset 
of  infantile  paralysis.  The  current  is  to  be  applied  to  the 
point  of  toleration,  for  five  minutes,  twice  daily.  This 
treatment  stimulates  vasomotor  contraction  of  the  hyper- 
emic  vessels,  tends  to  reduce  or  prevent  further  extravasa- 
tion of  their  fluid  contents,  sterilizes  the  infected  tissues, 
and  inhibits  the  progress  of  the  ascending  lesion. 

I  have  found  that,  in  the  application  of  the  Oudin  or 
d'Arsonval  high-frequency  current  in  cases  of  obliterating 
endarteritis,  the  skin  became  blanched  and  remained  so  for 
several  minutes,  showing  that  the  primary  effect  of  the 
high  frequency  is  a  contraction  of  the  blood-vessels.  \\  ith 
this  effect  in  view,  hoping  to  reduce  the  blood  and  serum 
compression  on  the  nerve-cells  in  the  spinal  cord,  1  have 


ELECTROTHERAPY. 


289 


in  the  first  few  days  of  the  paralysis  applied  this  current 
along  the  spinal  column,  irrespective  of  temperature  or 
other  symptoms,  and  feel  positive  that  I  have  relieved  the 
compression  in  the  cord  and  hastened  recovery.  I  will 
cite  one  case  of  many  :— 


Fig.  73. — Infantile  paralysis.     Gertrude  G. 

Gertrude  G.,  6  years  of  age ;  normal  delivery ;  previous  history 
not  pertinent.  1  was  called  by  Dr.  Brainglass  to  confirm  his  diag- 
nosis of  infantile  paralysis,  on  June  13,  1910.  Sister  of  the  patient 
had  had  the  disease  with  facial  involvement. 

\Yhen  I  saw  this  child  both  legs  were  involved ;  the  paralysis 
was  extending,  and  seemed  to  be  of  the  progressive  type.  Hoping 

19 


290  1XFAXT1LE    PARALYSIS. 

to  stay  the  advance  of  the  paralysis  and  expedite  a  recovery,  having 
explained  to  the  doctor  the  benefit  1  hoped  to  obtain  by  the  d'Arson- 
val  current,  and  receiving  the  concurrence  of  the  family,  I  had  the 
child  removed  to  the  Hospital  for  Deformities  and  Joint  Diseases, 
where,  after  the  first  two  days'  treatment  with  high  frequency  along 
the  spine,  particularly  over  the  lumbar  region,  a  marked  improve- 
ment in  the  child's  condition  with  no  advance  of  the  paralysis  was 
shown.  This  treatment  was  kept  up  and  combined  with  the  other 
treatment  of  massage  and  electricity. 

The  child  has  made  an  almost  perfect  recovery ;  can  bear  her 
weight  and  hop  on  either  leg,  and  walks  with  a  normal  gait. 

The  apparent  arrest  in  progression  of  an  ascending- 
paralysis  obtained  by  the  local  application  of  the  high- 
frequency  current  in  this  case  is  the  result  also  sought  in 
recent  experiments  as  to  the  effect  of  subdural  injections 
of  epinephrin  in  the  acute  stage  of  poliomyelitis. 

In  the  treatment  of  cases  during  the  summer  of  1907 
and  1908,  I  secured  results  from  the  application  of  the 
high-frequency  current  that  I  failed  to  secure  from  the 
use  of  adrenalin  or  ergot,  and  so  reported  to  the  American 
Electrotherapeutical  Association  at  the  annual  meeting, 
September  19,  1908.  (Frauenthal,  "Anterior  Poliomye- 
litis," Jour,  of  Adv.  Therapeutics,  May,  1909.) 

I  cannot  attribute  the  results  obtained  wholly  to  the 
vasoconstrictor  action  of  the  high-frequency  current,  and 
consider  that  the  vessel  walls  are  rendered  less  permeable, 
and  that  the  transudation  of  fluids  and  the  migration  of 
cells  are  checked,  by  a  direct  oxygenating  and  vivifying 
action  of  the  venous  blood.  I  consider  this  oxygenation 
of  sufficient  power  and  extent  to  partly  or  wholly  sterilize 
the  invaded  tissues  in  a  similar  manner  to  the  electric  steri- 
lization of  water. 

The  sterilization  of  drinking-water  is  secured  by  con- 
stantly passing  the  water  between  highly  charged  metal 
plates,  whose  electrification  liberates  oxygen  so  rapidly 


ELECTROTHERAPY. 


291 


that  an  ozonation  of  the  water  incompatible  with  bacterial 
existence  results.  This  system  of  sterilization  of  water  is 
so  far  superior  to  any  other  known  method  that  it  is  in  use- 


Fig.  74. — Infantile  paralysis.  (X.  Y. 
Hospital  for  Deformities  and  Joint 
Diseases.) 


Fig.  75. — Same  as  Fig.  74,  pos- 
terior view. 


in  many  municipal  water  plants  on  the  Continent,  and  has 
recently  been  installed  by  the  United  States  Government 
in  the  Philippines,  where  it  has  been  demonstrated  to  de- 
crease bacteria  and  the  virulence  of  toxins. 


292 


IX  FAX  TILE    PARALYSIS. 


Case  referred  to  the  Hospital  for  Deformities  and  Joint 
Diseases  by  Dr.  Reginald  11.  Sayro.  who  took  the  original  photo- 
graphs. Thi>  case  suffered  from  a  severe  attack  of  infantile 
paralysis  in  the  epidemic  of  1907.  The  original  in  diagnosis, 
from  pain,  \vas  rheumatism,  and  this  diagnosis  isas  concurred  b\ 


Fig.  76. — Same  as  Fig.  74, 
one  year  later. 


Fig.  77. — Same  as  Fig.  76,  pos- 
terior view. 


consultants.  Her  total  paralysis  was  not  noticed  until  two  weeks 
after  the  original  attack.  After  six  months  she  was  referred  to  an 
orthopedic  specialist,  and  she  journeyed  from  Yonkers  to  Xew 
York  once  a  week  to  receive  treatment,  which  consisted  of  electricity. 
The  journey  back  and  forth  completely  exhausted  her  for  twenty- 
four  hours. 

The  curvature  in  her  back  became  so  pronounced  that  a  brace 
was  applied.    The  deformity  progressing,  another  consultation,  with 


ELECTROTHERAPY.  293 

a  second  orthopedic  surgeon,  was  requested.  As  a  result  of  this 
consultation  a  Calot  jacket  was  applied ;  was  also  wearing  a  hrace 
on  her  right  foot.  Xo  improvement  was  noticed. 

Consultation  with  a  third  orthopedist  was  sought.  This  ortho- 
pedist endorsed  the  treatment  as  conducted. 

In  September,  1909,  she  was  >cen  in  consultation  by  Dr.  R.  H. 
Sayre,  who  recorded  her  condition  in  Figs.  74  and  j'^.  Regard- 
ing her  case  as  one  that  should  receive  aggressive  treatment,  she 
was  turned  over  to  me,  at  the  hospital,  where  for  three  months 
traction  was  made  on  her  extremities  and  head,  with  daily  electricity 
and  massage  to  her  weakened  muscles.  This  was  followed  by  a 
plaster  jacket  and  jury-mast. 

Photographs  taken  one  year  later,  as  shown  in  Figs.  76  and  77, 
show  marked  improvement ;  also  demonstrate  the  fact,  not  accepted 
by  many  orthopedists,  that  in  rotary  lateral  curvature,  with  bony  de- 
formity, much  improvement  can  take  place.  A  line  drawn  down 
from  the  left  nipple  in  the  front,  or  from  the  angle  of  the  scapula 
in  the  back,  or  following  the  crease  of  buttocks  up,  will  bring  out 
the  change  that  has  taken  place. 

Since  these  photographs  were  taken,  the  patient  has  made  de- 
cided improvement,  but  objects  to  having  another  photograph  taken. 

THE  COMBINED  GALVANIC  AND  FARADIC 
CURRENT  IN  THE  EARLY  TREAT- 
MENT OF  PARALYSIS. 

The  usual  advice  of  those  practitioners  who  advocate 
the  use  of  electricity  in  palsied  limbs  is  to  postpone  treat- 
ment for  a  period  of  six  or  eight  weeks  after  the  subsidence 
•  »f  the  acute  stage,  or  at  least  wait  for  defervescence.  They 
argue  that  the  stimulation  of  the  exhausted  neuron  by  any 
agent,  strychnine  or  electricity,  is  as  ill-advised  as  the  flog- 
ging of  a  dying  horse. 

The  first  requisite  of  electrotherapy  in  paralysis  is  the 
maintenance  of  muscular  integrity  during  the  period  in 
which  the  injured  neurons  remain  in  a  state  of  suspended 
animation,  or  until  contiguous  nerve-fibers  take  on  the 
function  of  necrosed  ganglionic  units.  Advanced  muscular 


294  INFANTILE    PARALYSIS. 

atrophy  is  a  not  uncommon  discovery  at  the  close  of  the 
seo  >nd  week  after  the  advent  of  paralysis.  Is  it  good 
therapy  to  allow  a  degeneration  to  proceed  for  six  weeks 
which  will  hardly  permit  of  regeneration  in  a  year's  time, 
if  at  all?  The  treatment  at  this  period  should  seek  to  pro- 
vide rest/  recuperation,  and  nutrition  for  the  injured 
neurons ;  should  minimize  pain,  correct  postural  deformi- 
ties, and  maintain  muscular  integrity. 

It  is  during  this  period,  while  hyperesthesias  interdict 
massage  and  passive  motion,  that  a  mild  current,  applied 
only  to  the  origin  and  insertion  of  the  affected  muscles,  for 
brief  periods,  once  daily,  offers  the  only  known  means  of 
inhibiting  muscular  atrophy  until  such  time  as  a  beginning 
regeneration  of  the  nerve-supply  of  the  part  obtains  and 
peripheral  function  comes  under  the  control  of  the  will. 

The  rule  of  the  Board  of  Health  of  Xew  York  City, 
which  makes  compulsory  the  isolation  for  six  weeks  of  the 
acute  case,  should  not  be  allowed  to  interfere  with  treat- 
ment at  this  important  period. 

We  know  that  wre  can  obtain  contraction  of  the  muscle 
by  means  of  electric  current  when  none  can  be  obtained  by 
the  will ;  hence,  this  is  a  valuable  means  of  retaining  and 
developing  the  muscle  fiber  until  it  comes  under  the  guid- 
ance of  the  mind. 

When  the  temperature  is  between  98.5°  and  99.5°  and 
in  some  cases  where  high  temperature  continues  for  several 
weeks,  I  have  not  let  this  deter  me  from  treating  the 
patient. 

I  give  to  the  muscles  involved  a  sinusoidal  current, 
alternating  every  second  day  with  a  combined  galvanic  and 
faradic  current  that  contracts  seventy-two  times  to  a 
minute,  synchronous  with  the  heart  beat  (such  a  clock 
arrangement  is  found  on  Victor  electric  plates,  and 
others)  ;  and  I  personally  regard  this  as  an  aid  in  the  effect. 


ELECTROTHERAPY. 


295 


Although  many  differences  of  opinion  prevail  as  to  the 
application  of  the  sponge  electrodes,  I  am  in  the  habit  of 
applying  them  at  the  origin  and  insertion  of  the  muscle 
«>r  muscle  groups  involved,  always  laying  stress  on  the 
importance  of  approximating  the  origin  and  insertion  of 
the  muscle  as  nearly  as  possible. 

For  instance,  in  treating  the  perineal  group,  these 
muscles  being  most  frequently  involved,  one  sponge  is 


Fig.  78.— Xo  treatment  for  fourteen  years  with  flail  arm  and  total 
disability.  Result  after  nine  months'  electrotherapy,  massage,  and 
muscle  training,  a  restoration  of  function  of  hand,  forearm,  and  arm. 
(X.  V.  Hospital  for  Deformities  and  Joint  Diseases.) 

placed  over  the  middle  third  of  the  outer  side  of  the  fibula, 
the  foot  flexed  as  much  above  a  right  angle  as  possible,  and 
the  other  sponge  applied  over  the  insertion  of  these  muscles 
<>n  the  outer  side  of  the  foot.  In  this  way  the  bellies  of  the 
muscles  are  relaxed  and  a  contraction  is  made  more  easily 
for  the  patient. 

The  strength  of  the  current  used  should  be  the  weakest 
that  will  produce  contraction,  and  it  is  never  to  be  used 


2%  INFANTILE    PARALYSIS. 

after  contraction  of  the  muscle  ceases,  nor  longer  than 
from  two  to  three  minutes  on  any  particular  muscle  group, 
or  from  six  to  ten  minutes  on  the  body  at  one  seance. 

If  this  method  is  followed  the  child  will  not  cry  from 
pain,  nor  have  it's  nervous  system  upset  by  too  long  con- 
tinued electric  treatment. 

The  blanket  therapy  of  applying  a  large  electrode  to 
the  spine  and  passing  the  second  electrode  over  the  entire 
surface  of  the  involved  limb,  we  consider  harmful,  at  least 
during  this  stage  of  the  lesion;  it  is  usually  painful,  and 
greatly  augments  the  pain  of  the  hyperesthetic  case. 

The  sponge  electrodes  are  to  be  kept  constantly  damp, 
and  a  square  of  gauze  interposed  between  the  electrode  and 
the  cutaneous  surface;  this  latter  precaution  is  to  be 
scrupulously  observed  when  successive  cases  are  under 
treatment. 

Tactfulness  is  a  large  asset  in  giving  electric  treatment 
to  young  children;  if  the  child's  confidence  is  gained  at 
once,  it  will  not  object  to  subsequent  handling.  The  cur- 
rent should  be  turned  off  until  the  electrodes  are  placed 
and  then  turned  on  with  entire  gentleness  only  until  a  con- 
traction is  perceptible  to  palpation,  by  the  index  finger 
placed  over  the  belly  of  the  muscle.  Avoid  raising  and  re- 
placing electrodes,  as  each  break  is  painful  to  the  hyper- 
esthetic  case.  Time  the  treatment  with  a  clock  and  do  not 
exceed  six  minutes  with  children,  nor  twelve  with  adults, 
at  this  early  stage.  These  periods  of  time  cover  the  whole 
treatment  with  a  proportional  amount  of  time  for  each  ex- 
tremity, i.e.,  three  minutes'  application  to  an  arm  or  a  leg 
is  ample.  A  more  extended  treatment  may  be  harmful.  A 
deleterious  result  would  follow  the  treatment  recently  ad- 
vocated by  a  coi'frcrc:  "Successively  lengthen  period  (of 
electric  treatment)  from  twenty-five  minutes  to  an  hour's 
duration"  (!  ). 


ELECTROTHERAPY.  297 

The  mild  treatment  just  outlined  will  frequently  prove 
restful  to  the  worn  and  helpless  sufferer,  and  will  induce 
the  first  restful  sleep  he  has  experienced  since  becoming  ill. 

If  medication  by  strychnine  is  desired,  the  drug  can  be 
used  locally  and  driven  directly  into  the  muscle  and  nerve- 


Fig.  79. — Perfect  result  following  treatment  at  N.  Y.  Hospital 
«  for  Deformities  and  Joint  Diseases. 

endings  during  the  electric  treatment.  Wet  the  electrodes 
in  a  solution  of  strychnine,  l/\o  grain  to  I  ounce  of  water. 
A  more  simple  and  less  dangerous  method  than  the  hypo- 
dermic injection  of  strychnine  in  young  children. 

"The  muscles  that  are  not  affected  are  frequently  treated,  by 
the  person  using  the  electricity,  to  the  detriment  of  the  patient  by 


298  1XFAXT1LE    PARALYSIS. 

increasing  the  contractures.  The  paralyzed  muscles  will  not  respond 
to  the  electric  current;  the  current  i>  increased,  and  by  extrapolar 
diffusion  of  the  current  muscles  not  paralyzed  are  made  to  contract 
again  and  again  and  contracture  and  deformity  may  be  increased. 
The  physician  not  thinking  of  the  physiologic  anatomy  treats  the 
muscles  unaffected  more  than  those  which  are  really  affected." 
(Mills,  Philadelphia.) 

M.  M.  Acute  attack  August  16,  1910.  Paralysis  of  both  lower 
extremities,  back,  right  upper  lid,  and  crossed  eyes.  l;ir>t  physician 
called  did  not  know  what  was  the  matter  with  her  according  to  the 
mother,  who  took  the  child  to  second  physician  (Koplik).  who  ap- 
plied cups  three  times  a  week  for  six  weeks.  In  November  the 
child  was  removed  to  Hospital  for  Deformities.  I'nder  treatment 
there  was  steady  renewal  of  function,  and  in  January,  1911.  the 
child  began  to  walk ;  a  perfect  result  followed. 

ELECTRIC   TREATMENT   OF  THE   CHRONIC 

PARALYTIC  AND  ATROPHIC  STAGE 
"By   a   proper   appreciation  of  the   available   therapeutic   and 
mechanical  agencies  we  need  rarely  if  ever  encounter  any  paralytic 
deformity."      (".Paralytic  Treatment."  page  41,  Jones.  Liverpool.) 

This  has  been  our  experience  with  cases  placed  early 
under  our  care.  Many  contractions  and  deformities  arc 
preventable,  first,  by  the  maintenance  of  the  integrity  of 
muscle  structure  where  weakness  would  allow  overaction 
on  the  part  of  unaffected  opponents,  and,  second,  bv  the 
use  of  plastic  splints.  F.verv  muscle  not  hopelessly  fibrosed 
should  be  given  a  course  of  electric  stimulation  for  an  in- 
definite period  of  time.  If  a  case  of  recent  or  long  standing 
present  with  a  paresis  or  atrophy  of  however  severe  degree, 
if  extreme  deformity  or  disability  demand  orthopedic  in- 
tervention, or  if  continuous  sensory  disturbances  combined 
with  motor  weakness  on  exertion  are  the  only  reminder- 
of  the  acute  attack,  electrification  of  nerve  and  muscle  i< 
the  valuable  adjuvant  to  other  treatment. 

Electric  stimulation  of  the  ganglionic  neuron  through 
its  peripheral  branch  directly  improves  local  nutrition,  in- 


ELECTROTHERAPY. 


299 


creases  the  caliber  of  the  nerve  of  conduction,  manifolds 
energy  transmission,  thus  securing  compensation  for  the 
decrease  in  muscle  mass. 


Fig.  80. — Acute  ascending  pa- 
ralysis, with  paralysis  of  diaphragm. 
(X.  V.  Hospital  for  Deformities 
and  Joint  Diseases.) 


Fig.  81. — Same  case  as  Fig.  80. 
Recovery. 


The  regeneration  of  nerves  is  apparent  in  the  class  of 
cases  which  present  extreme  muscular  atrophy,  yet  regain 
excellent  function  under  treatment;  this  regeneration  may 


300  INFANTILE    PARALYSIS. 

take  the  form  of  an  increase  in  calibration  of  the  nerve, 
implying  an  increase  in  power  of  transmission  similar  to 
the  increased  transmission  of  an  amplified  copper  wire; 
the  regeneration  may  be  due  to  the  taking  over  of  the 
function  of  one  impaired  neuron  by  a  healthy  neuron  ai  a 
lower  or  higher  uninvaded  level  of  the  cord.  This  is  based 
on  the  fact  that  in  investigation  of  localization  in  the  brain 
and  the  decussaiion  of  the  fibers,  lower  areas  have  been 
found  to  take  over  function  of  higher  levels  impaired  by 
injury  <>r  minor  growth. 

Mannie.  Acute  a.-cending  paralysis,  with  paralysis  of  the  dia- 
phragm, and  recovery.  This  case  was  referred  t<>  the  hospital  by 
Dr.  Koplik  seven  months  subsequent  to  initial  paralysis.  \Yhew 
admitted  there  was  paralysis  and  atrophy  of  all  extremities,  with 
involvement  of  the  pectorals,  intercostals.  and  diaphragm.  The 
right  arm  and  hand  presented  spasticity,  while  balance  of  muscles 
were  flaccid.  The  stage  was  considered  a  terminal  one  and  an 
autopsy  expected.  Reflexes  exaggerated  on  right  side ;  lost  on  left 
side.  Under  treatment,  there  was  a  slow  return  to  function.  At 
the  close  of  three  years'  continuous  treatment  with  massage,  elec- 
tricity, breathing  exercises,  and  muscle  reduction  the  muscle-  of 
both  legs  have  regained  normal  function,  the  left  arm  is  nearly 
normal,  the  right  deltoid  is  wholly  atrophic,  but  the  trapezius  and 
flexors  of  the  right  hand  functionate.  Some  atrophy  of  pectoral- 
and  intercostals  is  evident.  The  severity  of  the  case  and  the  ex- 
treme condition  at  the  close  of  the  fir.-t  seven  months  render  the 
present  recovery  remarkable. 

As  some  men  prominent  in  orthopedics  and  neurol<  >gy 
have  condemned  the  use  of  electricity  and  massage.  1  have 
taken  a  recent  article  as  illustrative  of  this  side  of  the  sub- 
ject, i.e.,  Dr.  Henry  Ling  Taylor,  professor  of  orthopedic 
surgery,  New  York  Post-graduate  School  and  Hospital ; 
adjunct  attending  surgeon,  Hospital  for  Ruptured  and 
Crippled  (Medical  Record,  October  15,  1910,  page  660) 
says:  "The  conventional  treatment  by  electricity  and  mas- 
sage is  completely  ineffectual."  To  further  support  this 


ELECTROTIIKkAI'V.  301 

position,  he  continues:  "This  was  publicly  acknowledged 
by  Dr.  Bernard  Sachs,  of  New  York,  a  distinguished  neu- 
rologist, etc.,  and  chairman  of  the  Collective  Investigation 
Committee  of  the  New  York  epidemic  of  1907,  at  the 
Congress  of  American  Physicians  and  Surgeons,  at  Wash- 
ington,'" May  10,  1910..  In  these  words  he  spoke  of  elec- 
tricity and  massage:  "I  consider  that  the  time  given  to 
massage  and  electricity,  in  these  cases,  is  time  wasted. 
I  cannot  see  that  these  same  methods  do  any  definite  good." 

It  is  true  that  Dr.  .Sachs  made  the  above  statement  in 
May,  1910,  as  I  was  present  at  the  time;  but  five  months 
later,  on  October  24,  1910,  at  the  New  York  Academy  of 
Medicine,  Dr.  Sachs,  in  discussing  this  subject,  spoke  of 
electricity  and  massage  in  the  highest  terms,  as  he  had 
previously  done  in  the  Journal  of  American  Medical  Asso- 
ciation, October  22,  1910,  page  1465,  in  the  following 
words:  "Electric  treatment  can  hardly  be  overdone.  It 
should  be  begun  about  one  week  after  the  subsidence  of  the 
febrile  period  and  should  be  continued  daily  until  full  re- 
covery .  .  .  .  or  a  chronic  stage  has  been  reached,"  et 
scq.,  thus  showing  that  a  man  of  the  highest  standing,  from 
a  later  and  more  comprehensive  knowledge  of  the  subject, 
completely  changed  his  views  of  the  value  of  electricity  and 
massage. 

That  Dr.  Taylor  is  unconsciously  in  accord  is  shown  on  ' 
the  next  page  of  his  own  article,  where  he  speaks  in  the 
highest  terms  of  vibration  (which  is  a  simple  mechanical 
massage)  and  active  and  passive  movements  (which  have 
always  been  classed  under  Swedish  massage). 

This  case  (Fig.  82)  is  shown  to  illustrate  how  massage 
and  electricity,  carried  out  by  the  parents  alone,  have  won 
success,  when  many  prominent  physicians,  who  were  con- 
sulted from  time  to  time,  made  the  darkest  prognosis,  with 
no  promise  of  the  use  of  either  limb :— 


302 


1  \1-.\\T I  LK    PARALYSIS. 


Olive  B.,  \vhen  \y>  years  of  age,  had  an  attack  of  infantile 
paralysis,  with  both  limbs  involved ;  patient  was  not  able  to  bear 
her  weight  on  either  limb  for  two  years.  During  this  time  various 
physicians  were  consulted,  and  the  mother  was  told  that  the  case- 
was  hopeless.  At  the  advice  of  an  old  physician,  the  mother  herself 


Fig.  82. — Success  with  massage  and  electricity. 

purchased  a  battery  and  gave  the  child  massage  and  electricity.  At 
a  later  time,  braces  were  ordered  by  institutions  and  applied,  but 
as  the  mother  thought  that  this  did  not  aid  in  the  recovery  they 
were  discarded. 

Nevertheless,  the  mother  proceeded  in  the  massage  and  elec- 
tricity "and  manipulation  to  bring  the  foot  around,"  keeping  up  the 


ELECTROTHERAPY.  303 

treatment  almost  daily  for  twenty  years.  The  girl,  as  I  now  present 
her,  is  24  years  of  age ;  has  no  difference  in  the  length  of  her  legs, 
but  the  right  foot  is  an  inch  and  a  half  shorter  than  the  left.  She 
is  just  recovering  from  a  corrective  operation  on  this  right  foot. 

In  the  Bulletin  on  Infantile  Paralysis  of  the  Massachu- 
setts State  Board  of  Health,  1909,  Drs.  Bradford,  Lovett, 
Brackett,  Thorndike,  Soutter  and  Osgood,  in  speaking  of 
the  treatment,  said:— 

Electricity. — The  different  forms  which  may  be  used  for  this 
are  the  galvanic,  faradic,  static  and  high-frequency  currents.  In 
the  early  stages  galvanism  should  be  used  on  the  nerve-trunks  and 
faradism  on  the  muscles,  so  long  as  their  irritability  for  contraction 
is  maintained.  \Yhen  the  irritability  of  contraction  to  the  faradic  is 
lost,  galvanism  should  be  used,  as  having  more  influence  on  nutri- 
tion. With  the  returning  muscle  irritability,  faradism  should  be 
used,  and  best  by  the  use  of  the  electrodes  over  the  muscle  points 
so  as  to  obtain  actual  contraction  of  muscles  rather  than  by  the 
application  of  the  electric  current  to  broad  surfaces.  This  serves 
as  a  distinct  exercise  to  the  muscle  during  its  early  stage  of  weak- 
contraction.  High-frequency  and  static  electricity  can  both  be 
used  for  their  influence  on  nutrition  rather  than  for  their  direct 
action  on  muscle  contraction.  It  may  be  stated,  in  this  connection, 
that  the  main  dependence  for  actual  results  must  be  placed  upon 
the  galvanic  and  faradic  currents. 

REACTION    OF    DEGENERATION. 

I  believe  much  foolish  stress  has  been  laid  upon  the 
reaction  of  degeneration,  and  I  wish  to  prove,  from  a  large 
practical  experience,  how  deceptive  it  may  be. 

Tt  is  said  that  a  failure  to  obtain  a  muscle  contraction 
by  a  galvanic  or  faradic  current  is  an  evidence  of  degenera- 
tion of  the  muscle  fiber  and  that  no  improvement  can  be 
looked  for  in  this  paralyzed  condition  in  the  future. 

Do  we  fail  to  obtain  a  contraction  in  most  cases  ?  Xo ! 
We  find  that  the  cutaneous  surface  will  not  tolerate  the 
pain  of  the  current  and  we  must  desist  before  contraction 


304  1. \I-.\.\T ILK    I'AK. \LVS1S. 

takes  place,  for  most  of  our  cases  occur  in  children  under 
5  years  of  age,  and  they  see  no  reason  for  enduring  the 
electric  pain.  This  is  even  true  in  other  cases,  when  the 
age  of  the  patient  and  his  cutaneous  tolerance  are  greater ; 
the  strong  currents  may  give  no  reaction  and  still  reap- 
pearance of  function  may  occur. 

Case  B  is  shown  to  correct  two  long-estahlished  falla- 
cies: One,  that  no  improvement  will  occur  whether  spon- 
taneous or  under  treatment  after  one  year;  many  say  six 
months.  The  other,  that  after  failure  to  react  to  either  the 
galvanic  or  faradic  current,  known  as  the  reaction  of 
degeneration,  no  improvement  can  be  looked  for. 

Frank  S.,  boy  16  years  old;  when  il/2  years  old  had  an  attack 
of  infantile  paralysis  involving  his  face  and  arm ;  fourteen  years 
after  this  attack  appeared  at  the  Hospital  for  Deformities  and  Joint 
Diseases,  hoping  to  receive  treatment  that  would  improve  the 
condition  of  his  face.  He  was  turned  over  to  Dr.  Chas.  Rosenheck, 
who  had  had  five  years'  experience  at  the  Roosevelt  Hospital  dis- 
pensary (department  of  neurological  diseases)  and  also  at  the 
Harlem  Hospital  dispensary  (neurological  department),  and  who 
reported  to  me  that  he  was  satisfied  that  his  reaction  of  degenera- 
tion was  such  as  to  be  beyond  all  hope  of  the  slightest  benefit.  I 
requested  the  other  members  of  the  staff  to  confirm  this  condition, 
as  I  wished  to  see  if,  after  the  lapse  of  fourteen  years,  with  a  posi- 
tive reaction  of  degeneration,  any  improvement  could  take  place. 
The  improvement  was  so  great  after  being  under  constant  treatment 
for  six  months  (the  boy  being  able  to  close  eye  and  produce  wrinkles 
in  his  forehead,  with  a  return  to  the  normal  outline  of  the  affected 
side  of  his  face)  that  he  was  shown  at  the  Pediatric.  Xcurological. 
Orthopedic,  and  other  sections  of  the  Academy  of  Medicine.  Many 
other  similar  cases  have  been  encountered. 

Hofer  was  able  to  demonstrate  anatomically  the  mis- 
leading character  of  the  reaction  of  degeneration  in  son  it- 
cases.  He  cut  down  on  muscles  which  had  given  the 
reaction  of  degeneration  and  found  normal  muscle  fiber. 


ELECTROTHERAPY.  305 

PRESENCE  OF  PAIN  DURING  ELECTRIC 
TREATMENTS. 

The  induction  of  pain  during  electric  treatment  is  due 
to  its  improper  use ;  the  strength  of  the  current  should  al- 
ways be  regulated  so  that  contractions  do  not  induce  pain. 
\Yhen  the  parents  stated  that  the  treatment  excites  the 
child,  the  excitement  was  due  not  to  the  use  but  the  abuse 


Fig.  83. — Infantile  paralysis  at  1;_<  years  of  age;  at  16  great 
improvement  after  six  months'  constant  treatment.  (X.  Y.  Hospital 
for  Deformities  and  Joint  Diseases.) 

of  the  electricity.  Continued  overuse  will  result  in  a  de- 
struction of  nerve-cells,  a  very  detrimental  effect,  accom- 
panied by  a  hysteric  condition. 

In  conclusion,  I  wish  to  recall  some  salient  points : — 

1.  Treatment  should  begin  immediately  after  paralysis 
appears,  but  should  be  mild  in  the  beginning. 

2.  The  application  of  high  frequency  over  the  spinal 
column  by  its  contracting  action  relieves  the  compression 
on  the  nerve-cells  in  the  cord  by  the  extravasated  blood 


306  INFANTILE    PARALYSIS. 

and  serum,  and  decreases  the  virulence  of  the  toxin,  in- 
hibiting further  extension  of  the  process. 

3.  We  obtain  muscular  contraction  by  the  galvanic  or 
funidic  current,  and  thus  prevent  muscle  atrophy  during 
that  period  in  which  the  muscles  have  not  yet  come  again 
under  the  control  of  the  will,  and  win  a  victory  from  what 
seems  positive  defeat.    This  I  have  proven  in  over  50  cases, 
who  have  had  previous  treatment  from  one  to  three  years, 
in  other  institutions,   without  the  ability  to  walk,  or  an 
ability  to  use  their  arms.     Many  of  these  cases  have  been 
shown  at  the  section  meetings  of  the  Academy  of  Medicine, 
Xew  York  City. 

4.  The  electric  current  should  be  the  weakest  that  will 
produce  a  muscular  contraction,  and  should  not  be  con- 
tinued in  weak  muscles  when  contraction  ceases. 

5.  \Ye  should  approximate  the  origin  and  insertion  of 
muscles  when  applying  electricity. 

As  a  final  summary  of  my  own  personal  estimation  of 
the  relative  value  of  electricity,  active  muscle  education  and 
massage,  in  the  treatment  of  infantile  paralysis,  it  is  my 
opinion  that  the  rating  of  good  accomplished  would  be  55 
per  cent,  from  electricity  in  its  various  forms,  25  per  cent, 
from  muscle  education  combined  with  mental  concentra- 
tion on  the  physical  effort,  and  20  per  cent,  from  muscle 
stimulation  by  massage. 


CHAPTER   XIV. 

Physical  Therapy,  Massage,  and  Passive 
Motion. 


PHYSICAL  THERAPY. 

PHYSICAL  therapy  is  the  reliance  of  the  physician 
throughout  the  total  period  of  treatment  of  paralytic  cases 
of  poliomyelitis.  In  cases  not  requiring  corrective  appa- 
ratus and  intervention  it  is  the  chief  treatment ;  in  cases  re- 
quiring orthopedic  correction  it  has  become  more  and  more 
evident  that  the  final  success  of  the  correction  is  dependent 
<  ai  supplementary  untiring  and  intelligent  physical  therapy. 
Recent  demonstrations  of  the  value  of  physical  therapy  in 
the  treatment  of  the  chronic  stage  of  infantile  paralysis 
have  contributed  to  the  final  recognition  of  long-ignored 
measures;  we  have  noted  with  interest  the  acknowledgment 
from  Dr.  Hobart  Amory  Hare,  of  Philadelphia,  to  the 
effect  that  he  now  tells  .his  students  to  use  physical 
measures  wherever  possible,  to  the  exclusion  of  drugs. 

i  Ivdrotherapy  and  electrotherapy  have  been  considered 
elsewhere;  we  now  come  to  the  consideration  of  massage, 
passive  movements,  resistance  c.rcrciscs,  and  muscle  train- 
ing and  re-education: — 

I.  The  massage  of  a  paretic  muscle  maintains  nutrition 
by   artificially    stimulating   the   muscle   cell,    milking   the 
venous  blood  from  the  part,  inducing  secondary  hyperemia 
and  the  local  elevation  of  a  depressed  temperature. 

II.  I'assk'c  uiorcments  maintain  the  normal  range  of 
motion  of  the  joint,  tending  to  prevent  contraction;  they 
are  also  the  first  step  in  muscle  training  and  re-education. 

(307) 


308  IX  FAX  TILL    PARALYSIS. 

III.  Resistance  exercises.     \\'eakened  muscles   which 
yet  retain  some  voluntary  motion  can  be  advantageously 
developed  by  discreet  opposition  of  these  movements  by 
the  operator  (masseur).     Mechanotherapy  and  the  princi- 
ple of  the  Zander  machines  are  developments  of  the  re- 
-Munce  exercise,  and  are  of  great  value  when  power  for 
operation  by  the  patient  is  attained. 

IV.  Muscle  training  and  re-education  is  called  into  play 
in  that  large  class  of  cases  in  which  the  muscle  sense  is 
temporarily  in  abeyance  due  to  a  condition  of  suspended 
animation  of  the  ganglionic  neuron,  or  in  which  the  motor 
function  is  taken  over  by  uninvaded  cells  at  another  level 
of  the  cord. 

MASSAGE. 

I.  Medical  massage  dates  from  the  work  of  Dr.  Metz- 
ger,  of  Amsterdam,  and  his  followers,  and  his  classification 
in  a  great  measure  still  prevails. 

1.  \Ye  have  the  passive  movements  which  are  given  to 
the  patient  by  the  operator. 

2.  Active  movements  made  by  the  patient  with  the  as- 
sistance or  resistance  of  the  operator. 

The  following  are  the  manipulations:— 

1.  Efflenrage    consists    of    a    centripetal    stroking    by 
means  of  the  inner  side  of  the  thumb  and  first  finger, 
the  space  of  the  hand  intervening,  milking  and  pressing 
the  blood  and  lymph  from  the  extremities  toward  the  body. 

2.  Frictions  are  given  with  the  thumb  or  the  tips  of 
fingers;  they  are  strong,  circular  manipulations  and  are 
always  followed  by  centripetal  stroking. 

3.  Petrissage    (kneading) ;  this   manipulation   is   per- 
formed by  the  tips  of  the  thumb  or  the  palm  of  the  finger; 
it  is  used  principally  on  the  extremities. 

4.  Tapotenient     (percussion)     is     divided     into     five 
kinds: — 


PHYSICAL   THERAPY,   MASSAGE,  AXD   PASSIVE  MOTION.      309 

(a)  Clapping,  which  is  performed  by  the  palm  of  the 
hand. 

(b)  Hacking,  with  the  itlnar  border  of  the  hand. 

(c)  Punctaiion,  with  the  tips  of  the  finger-. 

(d)  Beating,  with  the  clenched  hand. 

(e)  Vibration,  as  the  friction  of  the  vibrator. 
Zabkulowski  has  shown  that  muscles  regain  their  apti- 


l;i\r.  S4. — Mnssa.yv  ;m<l  resistance  exercises.     (N.  Y.  Hospital  for 
Deformities  and  Joint  Diseases.) 

tude  for  work  much  more  quickly  by  a  few  minutes  of 
mas-age  than  by  rest  for  a  longer  time. 

Dr.  Benjamin  Lee  ("Hare  System  of  Practical  Thera- 
peutics," vol.  ii,  page  321)  states:  "In  the  essential  paral- 
ysis of  infancy,  truly  wonderful  results  are  obtained  by 
massage." 

The  treatment  should  be  entered  upon  the  moment  the 
acute  inflammatory  symptoms  have  disappeared  and  be 


310  INFANTILE    PARALYSIS. 

continued  daily  in  the  face  of  seeming  absolute  ineffective- 
ness. Cases  in  which  no  improvement  can  be  detected  for 
long  periods  often  suddenly  begin  to  improve  and  progress 
with  great  rapidity. 

The  effect  of  massage  may  be  arranged  as  follows: 
Mechanical,  reflex,  thermal,  electric. 

1.  The  mechanical  effects  are  by  far  the  most  impor- 
tant.    They  consist  of  the  interchanging  of  cell  contents 
under  the  influence  of  alternate  pressure  and  relaxation; 
a  quickened  movement  of  the  blood  in  the  capillaries,  espe- 
cially in  the  muscular   tissue;   increased   activity   in   the 
movement  of  the  areolar  fluid;  acceleration  of  the  current.^ 
of  both  blood  and  lymph  in  their  respective  channels. 

2.  The  reflex  or  purely  nervous  effects  of  massage  are 
obtained  by  light  stroking  and  percussion.     The  former 
produces  results  which  can  only  be  explained  on  the  sup- 
position that  it  acts  as  a  stimulant  to  the  reflex  system  of 
nerves,  the  force  used  not  being  sufficient  to  account  for 
any  change  on  the  mechanical  theory. 

3.  The  thermal  effects  of  massage  and  movements  are 
almost  too  apparent  to  need  scientific  demonstration ;  every- 
one is  familiar  with  the  fact  that  both  muscular  contraction 
in  the  form  of  ordinary  exercise  and  simple  friction  develop 
bodily  heat  in  a  striking  degree.    Dr.  Weir  Mitchell,  in  hi< 
essay  on  "Fat,  Blood,  and  How  to  Obtain  Them,"  note- 
that  he  has  frequently  seen  the  strangely  cold  limbs  of  chil- 
dren suffering  with  infantile  paralysis  gain  from  6°  to  io? 
F.  during  massage. 

4.  The  electric  effect  of  massage  results  partly  from 
the  development  of  the  surface  heat,  partly  from  the  sur- 
face friction,  partly  from  the  attrition  of  the  muscular 
fibers  and  cells,  partly  from   the  nerve   stimulation   and 
chemical  action. 

Most  of  the  massage  treatment  given  to  affected  chil- 


PHYSICAL  THERAPY,   MASSAGE,  AXU  PASSIVE  MOT1OX.      31 1 

dren  consists  of  rubbing  the  skin,  or  moving  the  skin  on 
the  underlying  fascia.  To  obtain  the  result  desired  and  do 
the  most  efficient  work,  we  grasp  between  the  thumb  and 
first  ringer  all  the  tissue  between  the  skin  and  bone,  and  by 
a  process  of  pressing  and  milking,  going  from  the  extrem- 


Fisr.  85. 


Figs.  85  and  86. — Total  paralysis  of  both  legs.  Treatment  with 
massage,  electrotherapy,  muscle  training.  Perfect  function.  No 
atrophy.  (X.  Y.  Hospital  for  Deformities  and  Joint  Diseases.) 


ity  toward  the  body,  the  veins  and  lymphatics  are  emptied 
and  elimination  and  assimilation  improved.  Deep  knead- 
ing and  brisk  striking  with  the  back  of  the  first  phalanx 
help  to  produce  hyperemia.  Vibration  properly  given  is  a 
good  substitute  for  massage.  By  such  an  application  of 


312  1X1-AXT1LE    PARALYSIS. 

thorough  massage  the  local   temperature  of  the  skin   is 
raised  from  one  to  three  degrees. 

Graham  observes  that  muscles  give  a  much  more  ready, 
vigorous  and  agreeable  response  to  the  will  and  to  the 
faradic  current  after  massage  than  they  did  before. 

A  child  suffering  from  infantile  paralysis  was  intro- 
duced; the  affected  limb  having  a  surface  temperature  of 
70°  F.,  the  poles  of  a  battery  were  applied  to  a  limb,  and  1 1 
milliamperes  were  required  to  produce  muscular  contrac- 
tion ;  the  limb  was  then  massaged  and  the  temperature  was 
found  to  have  risen  to  95°  F. ;  the  poles  being  applied  at 
the  same  points,  contractions  followed  the  employment  of 
only  5  milliamperes.  It  is  evident,  therefore,  that  massage 
diminishes  the  resistance  of  the  tissues  to  the  electric 
current  and  increases  the  electric  contractibility  of  the 
muscles. 

An  eminent  authority  recently,  said  that  in  the  treat- 
ment of  infantile  paralysis  there  was  no  virtue  in  drugs  or 
electricity,  and  the  only  treatment  that  was  beneficial  was 
massage,  and  anyone  could  give  that,  and  he  had  it  done  by 
the  child's  maid.  Why  should  we  be  surprised  at  the 
growth  of  osteopathy  and  Christian  Science,  if  such  treat 
ment  is  all  we  can  offer  to  the  parents  of  children  affected 
with  infantile  paralysis? 

The  nerves  in  exposed  areas,  as  the  ulnar  and  musculo- 
spiral,  the  sciatic,  peroneal  and  posterior  tibial,  should  be 
protected  from  injury  when  giving  deep  massage.  Un- 
doubted cases  of  neuritis  are  not  infrequent  sequehe  of 
poliomyelitis,  and  may  remain  an  incurable  and  lifelong 
affliction  of  the  patient;  we  should  see  that  they  are  never 
induced  by  trauma 

When  the  patient  is  receiving  the  combined  treatment 
of  massage,  electrotherapy,  and  muscle  training,  ten 
minutes  are  sufficient  time  for  each.  I  have  seen  several 


PHYSICAL  THERAPY,   MASSAGE,  AND  PASSIVE   MOTION.      313 

cases  of  too  prolonged  massage  treatment.     To  illustrate 
this  I  will  cite  2  cases:— 

L.  H.  Bethlehem:  Child  had  a  very  severe  attack  of  infantile 
paralysis,  involving  the  extremities,  back,  abdomen  and  chest 
muscles,  with  total  exhaustion  and  all  muscles  flaccid ;  he  received 
massage  for  an  hour  and  a  half,  or  more,  daily,  with  no  improve- 
ment, hut  great  exhaustion  followed  for  three  minutes  after  each 
application.  The  child  has  improved  decidedly  under  more  rational 
treatment  by  massage  and  electricity. 

Case  referred  by  Dr.  Taggart,  of  Atlantic  City :  Child  had 
involvement  of  left  leg  and  arm.  Treatment  was  given  for  one 
hour  three  times  a  day. 

A  strong,  healthy  man  finds  massage,  which  is  applied 
over  the  whole  body  for  an  hour,  a  physical  tax.  What 
must,  three  hours'  treatment  a  day  mean  to  muscles  de- 
vitalized by  the  lost  nerve-supply  of  infantile  paralysis? 

II.  The  period  during  which  passive  movements  are 
of  value  is  usually  short ;  as  soon  as  voluntary  motion  re- 
turns in  the  slightest  degree  it  should  be  utilized  until 
ingenuity  is  exhausted  in  devising  means  to  such  ends; 
according  to  Dr.  John  Ridlon,  active  movements  performed 
by  the  patient  himself  have  positive  curative  value  prob- 
ably greater  than  any  other  remedy. 

However,  there  is  a  field  for  passive  movement  early 
in  the  paretic  stage,  while  voluntary  movement  is  inhibited 
by  pain  and  fear  as  well  as  the  paresis;  passive  motions 
are  more  easily  accomplished  when  the  patient  is  in  the 
immersion  bath,  whose  warmth  and  buoyancy  permit  a 
range  of  movement  painful  elsewhere.  Passive  motion 
assists  in  maintaining  the  range  of  movement  of  the  joint, 
in  that  it  exercises  the  paralyzed  muscle,  and  briefly  in- 
hibits the  overaction  of  the  unopposed  healthy  group. 

Passive  movements  performed  slowly  several  times  in 
sequence,  and  then  attempted  by  the  patient,  are  the  first 
step  in  muscle  re-education. 


CHAPTER    XV. 

Therapeutic  Exercises  Performed  Before 
a  Mirror. 

"What  the  mind  conceives  the  body  achieves." 

THE  purpose  of  this  chapter  is  to  call  attention  to  a 
method  nducting    therapeutic    exercises    before    a 

mirror   during   which   the   muscle   effort    is    directed   by 
mental  concentration  on  the  act. 

The  physiologic  entity-  of  man  of  a  muscular 

system,  a  neural  system,  and  a  life-giving  function  main- 
tained by*  the  viscera. — lungs,  heart,  stomach,  pancreas, 
liver,  spleen,  kidneys,  intestines,  etc.. — which  require  exer- 
cise for  proper  adjustment  and  functioning.  It  is  kn 
that  muscular  exercise  profoundly  affects  the  function 
respiration,  circulation,  nutrition  and  excretion,  while  the 
heat-controlling  mechanisms  of  the  skin  and  sweat-glands 
may  be  stimulated  thereby  to  greater  activity.  Hence,  in 
various  pans  of  the  body  much  can  be  accom- 
plished by  selecting  exercises  for  such  function  or  organ 
as  will  tend  to  re-establish  its  normal  relation  to  the 
economy. 

It  is  also  well  to  entertain  the  fact  that  mental  concen- 
tration has  a  stimulating  effect  on  growth,  whether  in 
intellectual  brain  development  accomplished  by  the  stud} 
of  higher  mathematics,  or  resulting  from  the  concentration 
of  effort  required  for  voluntary  muscle  contraction  attained 
by  gazing  at  the  reflection  of  the  particular  muscle  or 
muscle  group  in  a  mirror.  The  relative  power  of  mental 
concentration  is  the  accepted  measure  of  the  superior  it 
one  mind  over  another.  A  moment's  thought  makes  clear 
(3 


EXERCISES  PERFORMED  BEFORE  A  MIRROR. 


315 


the  fact  that  the  nerve  control  and  nerve  efficiency  dis- 
played by  the  Oriental  muscle  dancer  can  be  developed  by 
any  person  in  any  set  <>f  voluntary  muscles,  if  a  proper 


Fig.  87.  —  In  mirror  X  is  seen  foot  placed  at  right  angle  to  be 
brought  up  through  arc  of  30  degrees.  In  mirror  Z  observe  in- 
structor's hands  under  leg  and  foot.  (X.  V.  Hospital  for  Deformities 

and  Joint  Disea^- 


effort  is  made   for  development  of  sufficient  nerve  force 
and  nerve  control. 

\Ye  must  now  realize  that  the  concentration  of  the 
mind  on  the  muscular  effort  not  only  initiates  the  move- 
ment. but  determines  blood  to  the  controlling  nerve-centers. 


316 


1XFAXT1L1-:    PARALYSIS. 


Fig.  88. — Xnrmal  standing  position,  showing  deflection  of  spine 
before  mental  and  muscle  effort  for  correction.  (X.  Y.  Hospital  for 
Deformities  and  Joint  Diseases.) 


EXERCISES    PERFORMED    BEFORE    A    MIRROR.  317 


Pig   89 — Deflection  corrected.     Maximum  muscle  effort  at  point  of  pencil. 
(X.  Y.  Hospital  for  Deformities  and  Joint  Diseases.) 


318  INFANTILE    PARALYSIS. 

producing  growth  and  development  in  the  conducting 
nerve-trunk  to  its  most  distant  filament.  It  was  demon- 
strated by  Anderson,  of  Yale,  and  others  that  when  a 
person  is  securely  placed  on  a  body  balance,  and  concen- 
trates his  mind  on  one  extremity,  the  balance  tips  in  the 


Fig.  90. — Plumb-line  test  to  demonstrate   muscle   contraction.      (N.    V 
Hospital  for  Deformities  and  Joint  Diseases.) 

direction  of  this  limb,  showing  that  a  hyperemia,  a  true 
determination  of  blood  to  the  part,  had  been  secured. 

It  has  been  found,  in  post-mortem  examinations  of  the 
human  brain,  that  when  motion  of  an  extremity  is  guided 
by  mental  concentration  the  convolutions  of  the  gray 
matter  of  the  brain  presiding  over  this  motor  area  are  in- 
creased; the  reverse  of  this  process  has  been  frequently 


EXERCISES    PERFORMED    BEFORE   A    MIRROR.  319 

demonstrated:  post-mortem  examination  of  the  cerebral 
cortex  of  an  individual  minus  an  extremity  from  intra- 
uterine  amputation  demonstrates  lack  of  development  of 
the  cortical  center  for  that  area. 

Other  conditions  being  equalized,  that  is,  the  securing 


Fig.  91. — Plumb-line  test  to  demonstrate  muscle  control.  Xote 
approximation  of  waist  to  plumb  line  and  increased  bulk  of  left 
erector  spina?.  (X.  Y.  Hospital  for  Deformities  and  Joint  Diseases.) 

<»f  ample  nourishment  and  the  absence  of  undue  fatigue, 
the  stimulus  transmitted  from  the  brain  to  the  periphery 
depends  on  the  calibration  of  the  conducting  nerves,  as  the 
diameter  of  copper  wire  regulates  the  volume  of  electric 
current. 

Normal   and  equalized   conditions   are   not,   however, 
found  in  the  nerve-trunks  after  invasion  bv  an  attack  of 


320 


INFANTILE    PARALYSIS. 


poliomyelitis.  "The  anterior  roots  at  the  (affected)  level 
are  decreased  in  size.  A  similar  condition  exists  in  the 
motor  nerves"  i  Vulpius).  The  trophic  function  has  been 
seriously  impaired,  and  there  is  a  constant  condition  of 
hyperexcitability  which  produces  undue  fatigue.  In  addi- 


Fig.    92. — Muscle    effort    and    muscle    balance    (erector    spi: 
acquired  by  corrective   exercises   for  lateral   curvature.     Three-year 
student  at  leading  school  of  physical  culture.     Unaware  of   lateral 
curvature ;   subsequently  absolutely  corrected  by  Frauenthal  method. 
(X.  V.  Hospital  for  Deformities  and  Joint  Diseases.)* 

tion  some  filaments  have  suffered  degeneration  and  atrophy 
subsequent  to  the  destruction  of  their  peripheral  neuron. 
the  motor  cell. 

The  problem  of  the  mirror  work  to  be  described  is, 
then,  not  the  simple  problem  of  securing  a  certain  number 


EXERCISES  PERFORMED  BEFORE  A  MIRROR. 


321 
To 


of  contractions  daily  of  an  unused  and  paretic  muscle, 
achieve  a  good  end-result  we  must  produce:— 

1.  Muscular  contractions  to   (a)  prevent  the  atrophy 
of  disuse;  ( b )  promote  regeneration. 

2.  Determination  of  blood  for  nourishment  to  secure 
trophic  repair  and  growth  for  (a)  impaired  nerve-trunks; 


Fig.  93. — Therapeutic  exercise  before  a  mirror.     Individual  instruction. 
(X.  V.  Hospital  for  Deformities  and  Joint  Diseases.) 

( b)    paretic   muscles:    (c)    inhibited    structural    growth, 
cartilage,  and  bone. 

3.  Re-establishment  of  sensory  and  motor  impulse  to 
i  a  )  directly  increase  calibration  of  nerve;  (b)  co-ordinate 
nerve  impulse  now  wasted. 

4.  New    anastomotic   association   paths    for    impulses 
whose  motor  tract  or  level  has  been  seriously  invaded  or 
destroyed. 


21 


322  INFANTILE    PARALYSIS. 

The  effectiveness  of  the  following  method  outlined  has 
been  abundantly  demonstrated  by  the  results  we  have 
shown  from  time  to  time  with  cases  of  poliomyelitis  and 
locomotor  ataxia  in  various  clinics  held  during  the  past 
t\vem\  vears:— 

METHOD  OF  MIRROR  TREATMENT. 

Treatment  should  be  given  before  a  large  and  well- 
lighted  mirror,  so  that  the  patient  may  see  all  parts  of  his 
body  clearly.  There  should  be  no  clothing  in  use  which 
hampers  movement  or  obscures  the  view.  The  patient 
should  be  in  stockingfeet,  or  soft  moccasins.  \Ye  do  not 
sufficiently  appreciate  what  a  foot  can  do  when  un- 
trammeled. 

In  corrections  of  the  torso,  particularly  lateral  curva- 
tures, a  compound  mirror  is  needed,  and  should  be  so 
arranged  that  the  patient  can  constantly  and  without  effort 
observe  the  erection  of  the  spinal  and  other  muscles  of  the 
back. 

The  mirror  should  extend  to  the  floor ;  in  all  foot  work, 
and  most  of  the  leg  work,  and  also  in  the  stretching  and 
rising  for  lateral  curvature,  the  child's  vision  would  be  at 
once  obscured  by  a  mirror  hung  above  the  floor  line. 
\Yhile  some  of  this  work  can  be  done  on  an  absolutely 
steady  table  drawn  close  to  the  mirror,  a  rug  thrown  on 
the  floor  provides  a  base  of  operations  for  the  patient  whose 
stability  is  assured,  and  one  factor  of  distracted  attention 
is  thus  eliminated. 

The  most  important  factor  in  the  treatment  is  the  in- 
structor. A  trained  instructor  with  a  high  grade  of 
intelligence  is  needed  for  this,  work.  The  graduate  in 
physical  culture  needs  a  postgraduate  training  of  at  least 
one  year  to  become  proficient,  a  good  knowledge  of  anat- 
omy, tact,  patience,  and  the  personality  which  insures 


EXERCISES    PERFORMED    BEFORE   A    MIRROR. 


323 


obedience.  The  graduate  in  physical  culture  who  has 
acquired  muscle  control  by  persistent  training  is  the  be>t 
instructor. 

There  should  be  nothing  in  the  range  of  vision  to 
distract  the  attention  of  the  patient  from  the  work  in 
hand.  In  private  practice  at  office  or  home,  no  one  should 


Fig.  94. — Therapeutic  exercise  before  a  mirror.     Individual  instruction. 
(X.  V.  Hospital  for  Deformities  and  Joint  Diseases.) 

be  present  in  the  room  besides  the  instructor  and  the  pa- 
tient. Individual  treatment  is  desirable,  for  by  this  means 
we  have  obtained  the  best  results.  However,  in  institu- 
tional work,  children  over  3  years  of  age  are  given  in- 
struction in  groups  of  6  or  more.  \Ye  have  such  daily 
classes  at  the  Hospital  for  Deformities  and  Joint  Dis- 
eases. The  classes  have  been  visited  by  the  leading 
neurologists  and  pediatricians  of  New  York  City,  and  the 


324  INFANTILE    PARALYSIS. 

visitors  unite  in  wondering  and  favorably  comment  on  the 
ability  of  the  children  for  concentrated  work,  which  is 
continued  with  total  unconsciousness  of  the  presence  of 
strangers. 

Concentration,  directed  by  an  able  instructor,  is  the 
keynote  of  this  treatment,  to  which  the  mirror  forms  a 
most  valuable  aid.  The  patient's  whole  attention  must  be 
centered  on  the  part  under  treatment,  and  when  possible 
on  the  particular  muscles  involved.  \\'hen  the  child  ob- 
serves the  desired  action  taking  place  in  the  mirror,  and 
realizes  that  his  effort  is  bearing  fruit  after  a  few  days 
of  work,  it  is  surprising  the  excellent  effort  he  will  put 
forth. 

In  the  beginning,  light  massage  or  beating  of  the 
muscle  will  aid  its  action.  This  is  also  attained  by  approxi- 
mating the  origin  and  insertion  of  the  muscle,  which  in- 
creases the  belly  bulk,  with  a  corresponding  increase  in 
contractile  force.  The  instructor  must  make  clear  to  the 
patient  the  muscles  to  be  brought  into  use.  The  c<  mtraction 
should  be  made  slowly  for  maximum  effort  and  effect. 

When  the  contractile  force  is  not  sufficient  to  move  the 
limb,  the  instructor  aids  in  the  desired  motion,  at  the  same 
time  compelling  the  patient  to  make  all  mental  effort  toward 
its  attainment.  As  the  muscle  becomes  stronger,  the 
needed  assistance  is  lessened.  The  muscle  is  allowed  to 
take  up  more  of  the  work,  run  the.  whole  of  the  exercise, 
and  receive  the  maximum  amount  of  work  possible  in  its 
weakened  condition.  The  exercise  must  always  stop  short 
of  the  fatigue  point.  Fatigue,  if  encountered,  will  be  both 
mental  and  physical' and  partake  of  the  nature  of  neuras- 
thenia. One  must  be  guided  by  judgment  and  experience 
as  to  the  amount  of  exercise  to  be  used,  particularly  during 
the  first  instruction  with  seriously  impaired  muscles.  It  is 
here  again  that  the  services  of  a  competent  instructor  are 


EXERCISES    PERFORMED    HERWK    A    MIRROR. 


325 


invaluable  for  the  welfare  of  the  patient  and  the  results 
the  physician  desires  to  attain. 

The  muscles  most  frequently  involved  in  infantile  paral- 
ysis are  those  making  up  the  perineal  group.  Placing  the 
child  on  a  chair  in  a  comfortable  position  before  the  mirror, 


Fig.  95. — Suspension  correction  for  lateral  curvature.     (N.  Y. 
Hospital  for  Deformities  and  Joint  Diseases.) 

the  instructor  approximates  the  origin  and  insertion  of  the 
muscles  composing  the  group  by  bringing  the  foot  up  to  a 
right  angle  with  the  leg;  he  then  urges  the  child  to  aid 
in  bringing  up  the  small  toes  at  the  side  of  the  foot  through 
an  arc  of  about  30  degrees.  If  the  child  cannot  do  this 
alone,  the  instructor  places  one  hand  on  the  knee  to  keep 
the  leg  in  position,  and  the  other  hand  under  the  foot ;  this 
greatly  aids  the  child's  effort  to  make  the  required  con- 


326  I XI- AX  TILE    PARALYSIS. 

traction.  This  should  be  repeated  several  times,  but  never 
to  the  fatigue  point.  Each  set  of  muscles  should  be  con- 
tracted in  a  similar  manner.  If  the  motion  cannot  be 
brought  about,  still  the  mental  effort  should  be  made  for 
this  attainment.  As  a  result  of  using  this  method  I  have 
been  able  to  show  at  medical  clinics  43  ambulant  patients 
who  were  formerly  unable  to  walk  for  a  period  of  from 
nine  months  to  four  years.  Many  of  these  cases  had  been 
referred  to  the  institution  by  Drs.  Kerley,  Koplik.  Mandl, 
and  other  men  of  standing. 

In  the  treatment  of  lateral  curvature  due  to  infamil'- 
paralysis  (and  this  is  the  primary  cause  of  a  majority  of 
mild  as  well  as  very  deforming  cases  of  curvature)  we  are 
handling  paretic  or  paralyzed  muscles  on  one  side  of  the 
spine  and  unopposed,  overcontracted,  healthy  muscles  on 
the  opposite  side.  Securing  a  permanent  result  is  de- 
pendent on  the  success  in  equalizing  this  muscle  force,  or 
in  re-establishing  in  the  weaker  muscles  a  strength  equiva- 
lent to  that  on  the  opposite  side.  The  correction  effected 
by  Abbott's  overcorrection  method  is  promptly  lost  on 
removal  of  the  jacket  unless  this  muscle  re-education  and 
actual  renewal  is  attained.  Abbott  himself  now  follows 
up  the  overcorrection  with  muscle  education. 

I  have  seen  so  many  cases  of  return  of  function  to 
paralyzed  extremities  by  the  persistent  use  of  this  line  of 
treatment  that  I  would  advise  the  discouraged  to  renew 
effort,  expecting  to  meet  with  such  agreeable  surprise  as 
I  have  at  the  results  accomplished  by  the  work. 

Arthur  H.  after  initial  attack  received  four  months'  treatment 
at  one  clinic,  eight  months'  treatment  at  another  clinic,  and  on  goin.n 
to  the  third  clinic  an  operation  for  fixing  the  foot  and  ankle  \va> 
suggested,  as  apparently  there  was  extensive  atrophy  and  no  func- 
tion. 

At  that  time  she  (Mrs.  H.)  met  the  mother  of  a  patient  who 
had  had  her  child  for  treatment  at  the  second  institution  for  three 


EXERCISES    PERFORMED    BEFORE   A    MIRROR 


327 


years,  with  no  ability  to  stand  or  walk,  and  Mrs.  H.  was  informed 
by  her  that  under  treatment  at  the  1  lospital  for  Deformities  and 
Joint  Diseases  for  five  months  the  child  was  able  to  walk  without 
braces.  Mrs".  H.,  regarding  this  as  an  absurdity,  made  a  special 


Fig.  96. — Able  to  walk  with  almost  normal  gait  after  one  year's  treatment. 
(X.  V.  Hospital  for  Deformities  and  Joint  Diseases.) 

visit  to  the  child's  home,  and,  seeing  what  she  regarded  as  a  miracle, 
brought  her  child. 

This  child  was  under  treatment  for  seven  months  before  he 
gained  any  promise  of  bearing  his  weight  on  his  right  leg,  and  after 
one  year  he  is  able  to  walk  with  almost  normal  gait. 


328  INFANTILE    PARALYSIS. 

BREATHING   EXERCISES. 

The  alarming  increase  in  the  respiration  rate  during 
the  acute  stage  of  poliomyelitis  is  evidence  that  practical!} 
every  case  suffers  from  some  involvement  of  the  respiration 
center.  The  fatal  cases  are  usually  if  not  always  termi- 
nated by  paralysis  of  the  respiratory  tract.  Kvery  case  of 
upper-extremity  involvement  presents  some  atrophy  of  the 
serrati;  the  serrati  are  involved  in  all  cases  of  postparalytic 
scoliosis.  The  majority  of  these  children,  whether  left  with 
a  lesion  of  upper  or  lower  extremity,  present  a  very  indif- 
ferent chest  expansion;  this  is  so  noticeable  as  to  suggest 
that  the  so-called  phthisical  chest  is  the  inheritance  not 
from  a  tuberculous  ancestor,  but  from  one  who  had  had  an 
inhibiting  attack  of  poliomyelitis. 

To  overcome  this  serious  defect,  as  well  as  to  provide 
oxygenation  for  all  the  body  tissues,  breathing  exercise-- 
should be  made  a  constant  accompaniment  to  any  and  all 
physical  therapy  undertaken. 

Resistance  movements  and  muscle  training  are  of  most 
value  in  treatment.  The  earlier  they  can  be  begun  after 
the  subsidence  of  all  irritation,  the  better  the  outcome. 

It  has  been  the  attention  of  this  kind  that  has  yielded 
results  after  operation:  where  the  work  of  exercise  has 
produced  most  of  the  improvement  and  not  the  operation. 

AYe  have  found  that  there  is  invariably  some  regression 
of  the  original  paralysis,  and  the  best  results  therefore 
naturally  seem  to  be  obtained  from  the  treatment  of  cases 
referred  early  in  the  course  of  the  disease.  \Ye  believe 
that  the  best  results  of  treatment  do  result  from  treatment 
instituted  as  early  as  possible  and  judiciously  given:  we 
have,  however,  had  complete  restoration  of  function  in 
cases  referred  to  us  as  hopeless  and  with  complete  loss  of 
function  as  late  as  eight  months  after  the  acute  stage. 


EXERCISES    PERFORMED    BEFORK    A    MIRROR.  329 

In  several  cases  between  u  and  18  years  of  age  in 
which  the  patient  could  not  hold  any  article  in  the  grasp 
of  the  affected  hand,  and  no  improvement  had  been  noted 
for  periods  of  time  extending  to  >ix  years,  by  a  careful 
system  of  training  and  development  of  the  muscles  the 
hand  was  enabled  to  grasp  and  use  a  knife  or  fork,  and 
finer  movements  were  gradually  acquired  until  the  patient 
could  write  with  the  affected  hand. 

In  this  treatment,  time  should  not  be  considered  a 
factor,  either  in  a  hopeless  prognosis  or  in  the  discourage- 
ment which  causes  the  parent  to  stop  treatments.  Failure 
is  usually  the  result  of  neglect;  it  may  be  due  to  faulty 
methods  of  the  use  of  electricity  in  its  many  manifestations, 
to  overmassage  or  injudicious  exercise. 

The  apathetic  and  a\\kward  child  will  develop  enthu- 
siasm in  the  hands  of  a  skillful  and  tactful  instructor,  fresh 
association  paths  for  muscle  impulse  will  develop,  co-ordi- 
nation between  action  and  impulse  will  be  gradually  re- 
stored, while  at  the  same  time  deformities  arising  from  the 
overaction  of  unopposed  muscles  must  be  recognized  and 
inhibited. 

It  has  been  said  that  association  fibers  in  the  decussa- 
tion  tract  of  the  brain  are  able  to  take  on  the  function  of 
fibers  whose  cortical  relations  have  been  impaired.  If  this 
is  true  of  the  higher  centers,  we  are  justified  in  expecting 
a  similar  adjustment  of  transmission  of  impulse  in  the 
various  levels  of  the  cord.  Observation  demonstrates  that 
such  renewal  of  association  paths  occurs. 


CHAPTER   XVI. 

Mechanotherapy. 

MECHANICAL  apparatus  was  first  devised  for  the  bed- 
fast paralytic  with  muscles  atrophied  from  the  waist  down, 
to  enable  him  to  walk.  The  iliopsoas  muscle,  a  great 


Fig.  97. — Xight  support  for  foot  and  instep.    Aluminum.    Weight,  3l/>  drains 
(X.  Y.  Hospital  for  Deformities  and  Joint  Diseases.) 

levator  of  the  thigh,  takes  its  origin  and  innervation  in 
part  from  the  dorsal  spine;  it  is  therefore  found,  in 
numerous  cases  of  paraplegia,  that  the  iliopsoas  is  wholly 
unaffected,  and  may  be  utilized  in  locomotion,  once  the 
flaccid  limbs  are  stiffened  and  properly  supported.  Heine- 
constructed  a  primitive  brace  in  1840,  which  stiffened  the 
legs  of  a  paralytic,  and  took  its  support  from  a  metal  belt 
encircling  the  rim  of  the  pelvis ;  this  brace  was  successful 
and  a  drawing  of  it  was  published.  The  clever  mechanism 
stimulated  the  production  of  apparatus  with  more  delicate 
(330) 


MECHAXOTHERAPY. 


331 


Fisr.  98. 


•fie.  99. 


Figs.  98  and  99. — Private  patient  at  the  hospital  with  infantile 
paralysis  involving  muscles  of  both  legs  and  spine.  Able  to  get 
about  by  proper-fitting  braces.  Fig.  99  shows  anterior  view.  (X.  Y. 
Hospital  for  Deformities  and  Joint  Diseases.) 


332 


IXFAXTILIi    PARALYSIS. 


adjustment  and  adaptation,  until  today  in  England  and 
Germany  it  is  possible  to  secure  a  glove-fitting  support  of 
molded  leather  with  a  feather-weight  framework  of  hollow 
steel. 

It  has  been  found  that  splints  and  braces,  when  used 
understandingly,  are  of  value  in  the  treatment  of  infantile 


Fig.  100. — Same  as  Fig.  98,  posterior  view. 

paralysis  from  the  time  of  onset.  Their  abuse  in  the  hands 
of  the  unskillful  and  negligent  is  very  detrimental  to  the 
patient. 

I  wish  to  state  with  emphasis  that  any  type  of  apparatus 
that  is  bandaged  to  the  limb,  or  is  attached  with  straps  and 
buckles,  is  detrimental  to  the  paralyzed  muscles.  An 
atrophy  of  muscle  is  produced,  either  throughout  the 
muscle  length  or  locally.  \Yhere  the  collar  of  the  brace 


MECHAXOTHKRAPV 


333 


Figf  102. 


Figs.  101  and  102. — Neglected  case  of  paralysis  of  both  lower 
extremities  with  involvement  of  muscles  of  eye  (abducens  and  left 
oblique").  Boy  had  not  walked  until  splints  were  applied.  He  is  now 
improving  under  treatment  with  electrotherapy,  massage,  and  muscle 
training.  Fig.  102  shows  brace ;  motion  confined  to  one  axis. 


I    -  - 

and  an  indentation  of  the  muscle  substance. 
doe  t         CSSHR          'phy.  which  can  be  plainly  palpated. 
Another  prevailing  evil  is  the  encasing"  of  these  para- 
.  1  muse",  s  f-Paris  or  starch  bandages,  thus 

:finement  r.  I  >sure  atrophy  to  the  already 


Fig.    103. — Hyperextension  of  knees.     (X.  Y. 
Deformities  and  Joint  Disea- 

damaged  musculatore.  when  every  effort  should  be  made 
to  retain  the  tone  of  the  muscle  until  it  again  comes  under 
the  control  of  the  will  and  renews  its  function.  More 
damage  can  be  done  with  this  type  of  confinement  than  can 
be  regained  by  the  muscles  in  a  year's  treatment  and  with 
our  best  endeavor. 


:,'-_   ~       .TH.-.-  -  -  - 


Another  grave  objection  to  braces  k  that 

'-rr.  :     r  :"-.-     —^.-  -_.-.  : 


appluiirr   -hooW  be  used  dot  is  not  rupiui 


: 

-.  -      -  .- 


-  — 


daihr  to  permit  the  UrJimrrt  uutliucd  in  Ac 

-  "v 


\\  ith  this  liiiMt^tMM  ifisJinrilii 

:\r.  :  r.:e:~  •--  :   -  :-T^:T::7":  ?•-.- 


The  orthopedic  splint  or  brace-  is  used  ia  infndfe  for 


336 


INFANTILE  .PARALYSIS. 


ysis  as  a  (i)  prophylactic,  (2)  supportive,  and  (3)  cor- 
rective measure. 

i.  In  the  early  stage  during  onset  and  regression  of 
paralysis,  as  a  prophylactic  support  and  protection  from 
dragging  of  the  bed-coverings  or  faulty  posture. 


Fig.   106. — Paraplegia,  with  slight  spontaneous  improvement  of  muscles  of 
left  leg.     (N.  Y.  Hospital  for  Deformities  and  Joint  Diseases.) 

2.  During  the  first  months  of  convalescence  to  maintain 
function  and  nutrition,  to  inhibit  contractures,  to  lessen 
muscular  tension,  to  maintain  muscular  balance,  to  main- 
tain the  integrity  of  ligaments,  muscle  tendons,  and  joint 
capsules. 

3.  In  the  later  periods  of  the  disease,  mechanisms  are 


MECHAXOTHEKAPV. 


337 


used  for  the  fixation  and  limitation  of  mobility  of  flail  joints 
and  flaccid  extremities,  for  muscle  substitution,  and  to  cor- 
rect paralytic  deformity. 

Splints. — As  the  acute  constitutional  symptoms  of  the 


Fig.  107. 


Fig.  108. 


Figs.  107  and  108. — Same  as  Fig.  106  after  three  months'  treatment. 

attack  subside  a  lingering  neuritis  will  force  the  patient  to 
assume  the  most  comfortable  position,  and  one  which 
favors  the  unopposed  action  of  the  unaffected  muscles. 
Such  posture,  by  favoring  contractures,  conduces  to  the  de- 
velopment of  contractures  and  deformity.  This  is  par- 
ticularly true  of  the  child  or  youth  still  in  the  developmental 


23 


338 


INFANTILE    PARALYSIS. 


period,  whose  tissues  and  bones  may  be  considered  malle- 
able. Thus,  a  girl  of  1 5  years  of  age,  in  the  fourth  week 
of  an  attack  of  acute  poliomyelitis  (previously  diagnosed 
and  treated  as  rheumatic  fever),  was  found  with  marked 


Fig.  109.- -Old  operation  and  brace  treatment.  Uncured.  Note 
pressure  atrophy  from  brace.  Paralysis  of  both  lower  extremities. 
Overtreated  to  inhibition.  Final  recovery  on  moderate  treatment. 

contracture  of  leg  on  thigh,  and  a  footdrop,  both  of  which 
conditions  might  have  been  lessened  or  prevented  by  ligh1 
splinting. 

The  pressure  of  bed-clothes  on  the  paretic  foot  and 
ankle  is  obviated  by  the  use  of  a  light  aluminum  splint 
applied  to  the  heel  and  plantar  surface  of  the  foot,  and 


MECHAXOTHERAPY. 


339 


projecting  an  inch  or  more  beyond  the  great  toe.    The  use 
of  a  bed-cradle  is  directed  in  the  chapter  on  treatment. 

All  mechanisms  which  are  need  in  the  early  stage  of 
the  disease  to  inhibit  contractures  and  deformity  should 


Fig.  110. — P.  S.,  scoliosis  following  acute  poliomyelitis,  erect.     (N.  Y. 
Hospital  for  Deformities  and  Joint  Diseases.) 

be  devised  to  interfere  as  little  as  possible  with  circulation 
or  nutrition.  Plaster-of-Paris  bandages  encircling  the 
trunk  or  extremities  and  splints  tightly  secured  by  a  band- 
age are  not  to  be  used. 

Supportive  .  Ipparatus. — Mechanisms  which  aid  loco- 
motion and  activity  are  of  much  importance.     When  no 


340 


1XFAXT1  LI-:    PARALYSIS. 


deformity  exist1-;  the  loss  of  function  from  paralyzed 
muscles  can  he  supplemented  by  mechanical  contrivances 
which  make  the  hones  and  the  apparatus  unite  in  support- 
ing- the  body  weight.  The  exercise  thus  obtainable  develops 


Fig.  111. — Same  as  Fig.  110,  stooping. 

the  weakened  and  paretic  muscles,  resulting  in  a  restora- 
tion of  the  motor  function. 

The  simplest  mechanism  is  a  walking  chair. 

In  many  of  these  cases,  by  a  proper  application  of 
therapeutic  and  mechanical  agencies,  we  can  circumvent 
subsequent  deformity.  The  brace,  however,  must  not  be 
too  heavy,  and  the  adjustment  must  be  carefully  regulated. 


Fig.  112.— X-ray  of  spine  of  P.  S. 


MECHANOTHERAPY. 


341 


Jones,  of  Liverpool,  stales  that  "nothing  has  tended  more 
to  the  discredit  of  the  practice  of  orthopedics  than  the 
lumbersome  and  complicated  machinery  with  which  sur- 
geons have  loaded  their  unfortunate  patients."  It  f re- 


Fig.  113. — M.  K.,  scoliosis  following  acute  poliomyelitis,  erect.     (N.  Y. 
Hospital  for  Deformities  and  Joint  Diseases.) 

quently  happens  that  parents  realize  this  and  discard 
braces,  which  not  infrequently  are  found  to  weigh  from 
one-twelfth  to  one-eighth  of  the  weight  of  the  child.  J 
have  a  large  scrap-heap  of  such  useless  splints. 

Tn  the  chronic  stage  of  poliomyelitis  apparatus  is  used 
to  fix  the  flail  joint  and  limit  its  motion  to  one  axis  only, 


342  1XFAXT1LE    PARALYSIS. 

to  control  the  degree  of  motion  in  that  axis,  to  replace 
paralyzed  muscles,  and  to  correct  deformities. 

The  cheapest  form  of  splint  is  the  malleable-iron  rod 
bent  to  fit  the  part,  and  attached  to  the  body  with  leather 


Fig.  114. — Same  as  Fig.  113,  stooping. 

and  steel  bands.  The  more  intricate  modification  of  this 
apparatus,  made  of  steel,  is  provided  with  movable  lock 
joints,  which  may  be  fixed  or  released  at  will,  which  are 
further  controlled  with  a  front  and  back  stop,  the  joint 
being  uniaxial,  or  a  gimbal  joint  which  permits  lateral 
movement;  this  apparatus  also  takes  its  fixed  position  from 


Fig.  115. — X-ray  of  spine  of  M.  K. 


MECHAXOTHERAPV. 


343 


straps  and  bands  which  encircle  the  body  and  extremity. 
When  the  use  of  apparatus  is  to  be  temporary  only,  and 
for  one  of  the  working  class,  these  braces  are  sufficient. 


Fig.  116. 


Fig.  117. 


Figs.  116  and  117. — Extreme  kyphosis  following  acute  poliomyelitis. 
(X.  Y.  Hospital   for  Deformities  and  Joint  Diseases.) 

Made  of  the  lightest  construction  the  material  admits, 
readjusted  at  frequent  intervals,  removed  daily  for  the 
treatment  necessary  to  offset  pressure  atrophy  and  the 
interference  with  circulation,  they  are  indispensable  for 


344 


1 X 1- A  X  T I LE    PARALYS1 S. 


some  otherwise  helpless  cases.  The  pressure  of  the  en- 
circling band  has  been  avoided  in  an  apparatus  constructed 
by  skilled  artisans  in  England  and  Germany  in  which  the 
pressure  is  evenly  distributed  over  the  limb  or  torso  by 


Fig.  118. — Same  as  Fig.  116. 


Fig.  119. — Same  as  Fig.  116. 


the  use  of  molded  leather  sheaths.  (These  are  known  by 
the  name  of  the  first  manufacturer  as  braces. —  Messing.) 
A  cast  of  the  extremity  is  made,  and  to  this  the  wet  leather 
is  molded  and  left  a  considerable  period  of  time;  in  the 
mean  time  a  very  light  supportive  framework  is  con- 


MECHANOTHERAPY.  345 

structecl  of  hollow  steel  rules,  whose  construction  and 
mechanism  are  exactly  adapted  to  the  needs  of  the  wearer. 
The  frame\vork  and  its  sheathing  are  now  united  and  form 
ambulatory  splint  of  such  nice  adaptation  to  the  patient 
and  his  needs  as  to  be  wholly  concealed  by  a  shoe  and 
stocking.  This  apparatus  is  expensive  in  preparation,  and 


Fig.  120. — Scoliosis.     (X.  Y.  Hospital  for  Deformities 
and  Joint  Diseases.) 

in  maintenance,  for  the  parts  must  be  renewed,  the  leather 
wears  through,  splits  from  exposure  to  moisture,  etc.  Yet 
there  are  many  parents  in  this  country  who  greatly  desire 
to  save  the  tender-hearted  child  from  the  unpleasant  pub- 
licity of  visible  apparatus,  who  would  gladly  purchase  such 
apparatus,  and  rene\v  it  so  long  as  it  was  needed.  There  is 
an  opportunity  now  for  a  clever  artisan  and  mechanic  to 
build  up  a  business  in  this  line  in  every  large  city.  It  is 
a  matter  of  regret  that  such  apparatus  at  present  cannot 
be  obtained  in  America. 


346  INFANTILE   PARALYSIS. 

Paul  D..  acute  illness.  July,  igio.  Referred  by  Dr.  Chas.  G. 
Kerley.  Oct.  16,  1910.  Removed  to  hospital.  Paraplegia,  with 
slight  spontaneous  improvement  of  muscles  of  left  leg.  January. 
1911,  after  three  months'  treatment  the  boy  is  able  to  stand  alone 
in  the  lock-joint  braces,  is  able  to  lift  both  legs  to  an  equal  or  right 
angle,  and  to  bear  additional  weight  of  braces. 


Fig.    121. — Scoliosis    with    incor-  Fig.    122. — Scoliosis   with   correct 

rect  application  of  jacket.      (N.  V.  application  of  jacket.     (N.  Y.  Hos- 

Hospital  for  Deformities  and  Joint  pital     fot     Deformities    and     Joint 

Diseases.)  Diseases.) 

The  molded  leather  sheath  is,  however,  open  to  the 
same  objection,  although  in  a  much  lessened  degree,  which 
holds  in  regard  to  the  use  of  the  band  brace.  Vulpius.  wh«  • 
has  had  an  opportunity  to  make  use  of  and  observe  results 


MECHANOTHERAPY. 


347 


from  these  supports,  states,  in  his  work  on  infantile  paral- 
ysis: "The  atrophy  which  results  from  the  long  wearing 
of  an  apparatus  is  much  in  evidence  with  the  band  type  of 


Fig-.  123. — Hammock  suspension  sling  for  forcible  overcorrection 
of  scoliosis  while  applying  plaster  jacket.  (X.  Y.  Hospital  for  De- 
formities and  Joint  Diseases.) 

fixation,  hut  can  also  he  demonstrated  with  the  sheath  type, 
for  after  some  months  the  appliance  becomes  too  large,  and 
110  longer  fits  the  limb  closely.  The  subcutaneous  fat  is  the 
first  to  go,  followed  by  the  muscles,  and  finally  by  the  bones, 
as  the  Roentgen  rays  have  shown  us." 


348  INFANTILE    PARALYSIS. 

The  Substitute  Muscle  or  the  J:laslic  Tractor. — Spiral 
>teel  springs  and  india-rubber  bands  have  been  utilized 
with  great  ingenuity  to  replace  paralytic  muscles.  Thus 
an  artificial  quadriceps  has  been  arranged  of  two  strips  of 
stout  gartering  which  cross  the  knee  obliquely  and  are 
attached  to  the  leg  splints  right  and  left  above  the  knee. 


Fig.  124. — Plaster  jackets  for  scoliosis  applied  in  attitude  of 
overcorrection,  and  fenestrated  for  development  of  atrophied  muscle. 
(N.  Y.  Hospital  for  Deformities  and  Joint  Disc,- 


and  below  it;  the  crossing  is  further  articulated  to  a  semi- 
lunar  band  of  steel  which  is  hasped  to  the  artificial  knee- 
joint  right  and  left.  The  tensile  strength  of  the  elastic  is 
sufficient  to  overcome  and  oppose  the  flexors  of  the  knee, 
or,  at  any  rate,  "to  pull  the  affected  limb  into  the  extended 
position  as  soon  as  the  flexors  cease  to  act"  (Volkman  ). 
Similarly  an  artificial  gastrocnemius  of  spiral  spring<  takes 


MECHAXOTHERAPY.  349 

its  origin  from  the  back  of  the  leg  band  and  is  inserted 
into  the  shoe  just  above  the  back  of  the  heel. 

Mechanisms  for  Coutractures.— Mechanisms    for   the 
prevention  of  deformity  are   still   more  intricate  and  de- 


Fig.  125. — Plaster  jackets  for  scoliosis  applied  in  overcorrection, 
and  fcnestrated  for  development  of  atrophied  muscle  and  compressed 
Inns.  <  N".  V.  Hospital  for  Deformities  and  Joint  Diseases.) 

pend  upon  the  principle  of  continuous  mechanical  traction 
for  effective  results;  the  treatment  is  tedious,  expensive, 
and  uncertain  in  results,  and  it  is  questionable  if  this  treat- 
ment alone  would  successfully  prevent  or  correct  existing 
contractures. 


350  IXFAXTILE    PARALYSIS. 

THE  ANKLE-JOINT. 

The  most  frequent  defect  that  interferes  with  locomo- 
tion is  paralysis  of  the  peroneal  group,  and  muscles  about 
the  foot  and  ankle-joint.  In  mechanical  correction  it  must 
be  determined  whether  the  brace  should  be  directly  coapted 
with  the  foot,  or  attached  to  the  shoe.  A  brace  complete 
in  itself,  with  foot-plate  in  apposition,  will  permit  better 
opportunity  to  adjust  mechanical  ankle-joint,  and  may  be 
worn  with  shoe.  It  is  almost  impossible  for  the  artificial 
ankle-joint  to  be  properly  adjusted  when  the  brace  is  at- 
tached to  the  shoe. 


CHAPTER   XVII. 

Surgical  Treatment  of  Poliomyelitis. 

ALTHOUGH  many  cases  in  the  chronic  stage  of  infantile 
paralysis  arrive  at  a  condition  where  surgical  measures  are 
desirable,  our  attitude  toward  surgical  interference  is  al- 
ways a  conservative  one.  \Ye  have  found  that  some  of  the 
best  results  we  have  had  have  been  obtained  in  cases  which 
have  discontinued  attendance  at  other  clinics  because  opera- 
tion was  insisted  on,  and  in  which  our  end-results  were 
attained  without  recourse  to  surgery.  The  longer  operative 
procedure  is  deferred,  the  better  the  permanent  result  will 
be,  and  in  operations  about  joints  one  is  less  liable  to  inter- 
fere with  the  epiphysis  of  long  bones  and  thereby  defeat 
growth.  The  consensus  of  the  best  men  is  that  ankylosis  of 
knee  and  ankle  should  never  be  done  before  1 2  years  of  age. 
Many  operations  for  tendon  transplantation  and  joint 
stiffening  are  done  which  would  not  be  begun  if  the  true 
spirit  of  the  eleventh  commandment  was  observed;  nor 
would  the  surgeon  do  them  on  his  own  child,  for  by  patient 
care,  non-surgical  treatment,  and  attention  an  end-result 
much  more  gratifying  would  be  obtained. 

Many  cases  in  the  chronic  stage  of  poliomyelitis,  owing 
to  (a)  lack  of  treatment,  (b)  improper  treatment,  (c) 
faulty  application  of  braces,  (d)  sole  dependence  on  brace, 
arrive  at  a  condition  where  surgical  measures  are  neces- 
sary. 

The  operative  procedures  are  :— 

1.  Tendon  lengthening. 

2.  Tendon  shortening. 

3.  Tendon  and  muscle  transference. 

(351) 


352  IXFAXTILE    PARALYSIS. 

4.  The  application  of  artificial  tendons  and  ligaments. 

5.  Joint  stiffening;  arthrodesis. 

'».    Xerve  transference  and  nerve  grafting. 

It  has  been  observed  by  Jones,  of  Liverpool,  and  other 
<  trthopedic  surgeons  that,  contrary  to  general  expectation, 
paralyzed  limbs  are  most  tolerant  of  operative  interference ; 
wounds  heal  well  and  quickly,  and  suppuration  is  less  prone 
to  occur  than  after  operation  on  healthy  limbs.  Inasmuch 
as  the  tissues  of  these  limbs  have  lost  wholly  or  in  part 
their  trophic  control,  it  is  interesting  that  this  fact  has 
been  observed  and  recorded  by  operators. 

1.  TENDON  LENGTHENING. 

The  operation  of  subcutaneous  tenotomy  dates  from 
the  work  of  Stromeyer  in  1831.  This  is  a  simple  and  safe 
operation  for  the  correction  of  deformity,  if  one  is  familiar 
with  the  relation  of  the  nerves  and  arteries;  when  such 
relations  are  not  clearly  in  mind,  one  should  do  an  open 
operation;  the  open  method  is  also  the  operation  of  choice 
when  the  hamstring  muscles  are  the  point  of  attack. 

Resection  of  the  tendo  achillis.  The  peroneal  group 
of  muscles  is,  perhaps,  the  most  frequently  involved  of  all 
muscle  groups,  and  the  paralysis  is  followed  by  drop-foot 
(talipes  equinus),  which  is  augmented  by  the  unopposed 
action  of  the  posterior  group  of  muscles  terminating  in  the 
tendo  achillis.  The  cutting  of  this  tendon  is  a  very  simple 
operation. 

Technique  of  Operation  (Tenotomy  of  Tendo  .Ichillis  ). 
- — The  previously  sterilized  skin  surface  is  painted  with 
tincture  of  iodine,  3  per  cent,  solution.  A  small  opening- 
is  made  through  the  skin  one  inch  or  one  and  one-halt 
inches  above  the  os  calcis;  into  this  opening  a  blunt-pointed 
tenotome  is  thrust,  the  blade  facing  toward  the  skin,  with 
the  tendon  between  the  blade  and  skin;  the  foot,  flexed 


SURGICAL   TREATMENT    OF    POLIOMYELITIS. 


353 


sharply  on  the  ankle,  holds  the  tendon  taut,  while  by  a 
gradual  sawing  motion  the  tendon  is  cut  through.  When 
applying  the  dressings  care  should  be  taken  to  avoid  in- 
serting any  dressing  between  the  two  separate  ends  of  the 
tendon,  which  would  produce  non-union.  The  wound  is 
>ealed  with  surgeons'  plaster  and  the  foot  flexed  on  the 


I-'i.y.  12(i. — Old  talipes  with  atrophy.     Reduced  in  one  sitting.     (N.  Y. 
Hospital  for  Deformities  and  Joint  Diseases.) 

leg  in  an  overcorrected  position,  and  encased  in  plaster 
bandages. 

The  regenerated  tendon  is  much  stronger  if  the  full 
separation  is  done  immediately  at  the  time  of  its  severance. 
This  fact  was  first  demonstrated  by  Young,  of  Philadel- 
phia, in  operations  on  rabbits.  English  operators  prefer 
to  wait  until  partial  healing  takes  place,  when  they  subject 
the  tendon  to  stretching,  after  which  healing  is  allowed 
to  proceed. 

23 


354  IXFAXT1LE    PARALYSIS. 

In  operations  at  the  I  lospital  for  Treatment  of  De- 
formities and  Joint  Diseases  the  tendon  is  always  severed 
and  separated,  and  the  foot  overcorrected.  In  no  case 
have  we  failed  to  get  union. 

2.  TENDON  SHORTENING. 

It  is  the  rule  in  infantile  paralysis  to  find  the  weakened 
and  paretic  muscles  overstretched,  by  the  overact  ion  of 
the  unopposed,  unaffected,  antagonistic  group;  in  place 
of  lengthening  the  tendons  of  the  strongly  contracted 
healthy  muscles,  it  is  often  desirable  to  shorten  the 
stretched  tendon  of  the  relaxed  and  paretic  group. 
"Taking  in  the  slack"  is  accomplished  by  freeing  the 
tendon,  folding  the  tendon  on  itself,  and  sewing  the  folds 
together  with  silk.  \Yound  infection  is  to  be  avoided  with 
the  usual  surgical  technique,  the  wound  closed  with  sur- 
geons' plaster,  and  the  limb  retained  iri!  overcorrection 
until  healing  has  taken  place,  and  for  a  number  of  weeks 
subsequent  to  the  healing.  The  retention  dressing  should 
be  removed  for  massage  and  electric  treatment.  Para- 
lyzed muscles  can  often  be  restored  to  usefulness  by  short- 
ening their  tendons,  or  by  the  combined  operation  in  which 
tenotomy  is  done  on  the  spastic  antagonistic  group. 
Muscle  groups  which  seemed  almost  wholly  degenerated 
and  were  badly  stretched  have  resumed  motor  functioning 
when  the  slack  was  taken  up  in  this  manner. 

3.  MUSCLE   AND   TENDON   TRANSFERENCE. 

In  some  cases  of  partial  paralysis  muscular  balance  is 
re-established  by  the  transplantation  of  the  tendon  of  a 
sound  muscle  to  a  new  point  of  leverage  which  enables 
it  to  take  over  the  function  of  the  paralyzed  muscle  group. 
The  operation  originated  with  Nicoladoni  in  1882,  who 


SURGICAL   TREATMENT    OF    POLIOMYELITIS. 


355 


operated  on  a  patient  having-  talipes  calcaneus  and  suc- 
cessfully corrected  the  deformity  by  attaching  the  peronei 
to  the  tendo  achillis.  Parish  and  Drobnik  utilized  a  similar 
method  in  other  forms  of  club-foot  in  iS<)_\  and  were 
followed  by  \Yinkelmann,  Yulpius,  Goldthwait,  Long,  and 
Schrantz. 


Fi.y.  127. — Postoperative  club-foot.     (X.  Y.  Hospital  for 
Deformities  and  Joint  Diseases.) 

It  is  essential  to  ascertain  the  condition  of  the  adjacent 
muscles.  Movement  should  be  studied  in  the  uncorrected 
stage  and  the  activity  of  the  muscles  recorded.  If  there 
are  contractures  the  deformity  should  be  corrected,  and 
retention  dressings  worn  for  at  least  two  months,  when 
;i  second  study  is  made  of  the  force  of  muscular  contraction. 
The  muscle  to  be  transplanted  must  be  unaffected,  and 
show  no  reaction  of  degeneration.  Its  condition  can  be 


356  IXFAXTil.K    PARALYSIS. 

tested  by  a  longitudinal  incision  through  the  muscle  sheath; 
the  healthy  muscle  is  deep  red  in  color,  discolored  if  para- 
lyzed, and  a  pale  red  if  degeneration  of  the  muscle  fiber 
has  supervened.  This  knowledge,  a  contribution  from 
Hoffa,  is  very  important  in  making  the  tendon  transference 
successful. 

Two  methods  of  transference  have  been  used :  the  first 
method  employed  was  the  suturing  of  the  tendon  of  the 
healthy  muscle  into  the  tendon  sheath  of  the  paralytic 
muscle;  the  second  method,  however,  has  been  found  to 
secure  a  stronger  and  more  permanent  attachment  for  the 
new  levator,  whose  cut  end  is  inserted  and  attached  to  the 
periosteum  at  or  near  the  insertion  of  the  degenerated  and 
useless  mate. 

Surgical  Technique  of  Muscle  and  Tendon  Trans- 
ference.— The  previously  sterilized  skin  surfaces  are 
painted  with  a  3  per  cent,  solution  of  tincture  of  iodine. 
After  incision  the  lower  part  of  the  muscle  and  its  tendon 
are  freed  from  adhesions  sufficiently  to  admit  of  free 
play,  and  it  is  made  to  assume  a  straight  course  to  the  new 
point  of  leverage.  Shortening  is  attained  by  folding  the 
tendon  on  itself.  It  is  desirable  to  make  use  of  the  whole 
muscle;  when  this  is  impossible  the  tendon  may  be  split 
not  higher  than  the  muscle  belly,  or  interference  in  cir- 
culation and  necrosis  may  result.  One  part  of  the  split 
tendon  is  then  attached  to  the  new  point  of  leverage,  and 
the  newly  made  muscle  may  in  time  functionate  separately 
from  that  portion  from  which  it  has  been  ravished.  TlofFa 
states  that,  as  a  rule,  the  two  parts  of  the  muscle  continue 
to  act  together,  and  for  this  reason  no  part  of  the  muscle 
should  be  so  arranged  that  it  antagonizes  the  main  body. 
\Yhen  linear  freedom  and  proper  tension  are  secured  the 
tendon  is  reattached  at  the  new  site.  Numerous  methods 
are  used  for  the  periosteal  insertion.  Nutter  bores  a  hole 


SURGICAL    TREATMENT    OF    POLIOMYELITIS.  357 

in  the  bone  from  which  the  periosteum  has  been  freed,  and 
anchors  the  end  of  the  tendon  in  this  aperture.  Wolff 
grooves  the  bone  under  the  periosteum,  sutures  the  tendon 
to  it,  and  closes  the  periosteum  over  it.  Sherman  has 
made  use  of  silver  wire  to  suture  the  tendon  to  the  bone.  I 
have  obtained  uniformly  good  results  by  dividing  the  perios- 
teum, suturing  the  tendon  in  place  under  it,  and  then 
driving  a  U-nail  through  the  tendon  and  into  the  bone,  at 
the  same  time  using  care  to  not  strangulate  the  circulation 
in  the  tip.  Dressings  are  applied  in  a  position  of  over- 
correction  and  a  retention  apparatus  applied.  To  insure 
union  and  a  good  result  it  is  necessary  that  an  absolute 
asepsis  be  maintained  throughout  the  operation,  and  the 
Ksmarch  bandage  should  be  removed  several  minutes  and 
free  circulation  in  the  limb  assured  before  the  dressings 
are  applied. 

It  is  understood  that  this  operation  will  not  correct  an 
existing  deformity.  If  the  transplanted  muscle  is  sub- 
jected to  strain  it  will  gradually  relax.  Preoperative  cor- 
rection, with  the  use  of  retention  apparatus,  should 
precede  the  transference  by  six  or  eight  weeks.  The  after- 
treatment  is  of  equal  importance.  Overcorrection  is  to  be 
maintained  for  a  period  of  two  months  and  support  given 
for  four  succeeding  months.  Daily  massage,  or  electro- 
therapy, and  a  gradual  muscle  re-education  are  to  be 
initiated  early  in  the  third  week.  The  retention  apparatus 
must  be  constructed  with  this  in  view.  A  plaster  cast  can 
be  cut  in  half  for  easy  removal  and  reappliance. 

The  most  satisfactory  of  the  muscle-transference  opera- 
tions is  the  correction  of  a  talipes  equinus,  secured  by  at- 
taching the  extensor  proprius  pollicis  to  the  dorsal  surface 
of  the  second  phalanx  of  the  big  toe. 

The  results  of  tendon  transplantation  may  be  con- 
sidered good.  In  paralytic  affections  of  the  leg  and  foot 


358  INFANTILE    PARALYSIS. 

great  improvement  can  he  attained,  the  motion  may  not  be 
entirely  free,  and  yet  a  marked  advance  over  the  former 
condition  is  secured. 

4.  THE   APPLICATION    OF  ARTIFICIAL   TENDONS 
AND  LIGAMENTS. 

It  is  now  more  than  twenty  years  since  Glucke  first 
adapted  some  strands  of  silkworm  gut  as  a  bridge  between 
the  non-approximating  ends  of  a  tendon  which  had  been 
severed  by  trauma.  Five  years  later  Kummel  was  able  to 
demonstrate  that  silkworm-gut  artificial  tendons  became 
converted  into  fibrous  tissue.  Lange,  of  Munich,  made 
use  of  this  valuable  discovery  and  extended  its  usefuliK-  : 
using  strands  of  silk  in  place  of  the  silkworm  gut,  Lange 
used  the  silk  to  reinforce  atrophic  tendons  incapable  of 
tension,  and  to  extend  healthy  tendons  which  failed  other- 
wise to  approximate  the  new  point  of  leverage.  Thus,  in 
paralysis  of  the  quadriceps  extensor  with  inability  to  ex- 
tend the  leg,  Lange  secured  excellent  function  by  utilizing 
the  freed  tendons  of  the  biceps  and  semitendinosus,  which 
were  threaded  with  strong  silk,  which  was  in  turn  firmly 
anchored  in  the  periosteum  of  the  tubercle  of  the  tibia. 

Technique  of  Operation.— The  field  of  operation,  hav- 
ing previously  been  sterilized,  is  painted  with  a  3  per  cent. 
solution  of  the  tincture  of  iodine.  The  incision  should  be 
long  enough  to  give  a  clear  field.  Protect  exposed  tendons 
and  muscles  from  drying  by  covering  with  moist  dressings 
or  sterilized  vaselin.  Stitch  the  silk  strands  securely  into 
the  tendon;  this  is  accomplished  by  a  suture  which  extends 
at  least  two  inches  into  the  substance  of  the  tendon,  where 
a  sharp  U-turn  is  made  and  the  suture  is  continued  back 
to  the  point  of  entrance;  the  tendon  is  now  provided  with 
an  extension  of  two  long  strands  of  silk.  Long,  strong 
metal  forceps  are  used  to  pass  or  draw  through  the  sub- 


SURGICAL    TREATMENT    OE    POLIOMYELITIS. 


359 


cutaneous  fatty  tissue  the  tendon  and  muscle  which  are  to 
be  transferred.  The  artificial  tendon  is  attached  to  the 
new  point  of  leverage  on  the  bone  by  stitching  it  directly 


I 


ff 

I 


Fig.  128. — Frauenthal  brace. 

to  the  periosteum.  In  children  it  may  be  stitched  through 
the  cartilage,  but  never  into  the  joint.  The  silk  is  prepared 
beforehand  by  boiling  in  a  i :  TOGO  solution  of  bichloride  of 
mercury  for  fifteen  minutes,  and  subsequently  in  sterilized 
paraffin  of  a  melting  point  of  155°  for  the  same  length  of 


360  INFANTILE    PARALYSIS. 

time;  before  use  the  strands  should  be  warmed  to  soften 
the  paraffin.  Xumber  14  braided  silk  is  the  preferred 
quality  at  our  clinics.  In  the  postoperative  dressing  the 
leg  is  adjusted  to  relieve  tension  as  far  as  possible  and 
plaster-of-Paris  bandages  applied  over  the  sterilized  dress- 
ings and  cotton.  This  type  of  dressing  is  continued  for 
about  six  weeks,  and  is  followed  by  some  mechanical  pro- 
tective appliance,  which  is  retained  for  six  or  eight  months 
and  gradually  dispensed  with. 

Lange,  of  Munich,  has  employed  artificial  tendons  in 
56  cases  of  tendon  transplantation,  of  which  54  cases  were 
successful.  The  silk  tendons  were  found  to  be  very 
durable,  and  after  some  months  of  use  were  found  to  be 
gradually  acquiring  a  reinforcement  of  fibrous  tissue,  which 
steadily  increased  in  thickness  with  the  action  of  the  trans- 
planted muscles : — 

In  the  case  of  a  girl  in  whom  a  silk  tendon,  made  two  and  a 
half  years  before  for  paralysis  of  the  quadriceps  muscle,  proved  too 
long,  an  incision  was  made  below  the  patella  in  order  to  shorten  the 
tendon.  It  was  easily  found  in  the  subcutaneous  connective  tis-m. 
and  was  surrounded  by  a  loose  and  movable  connective  tissue. 
There  was  no  true  tendon  sheath.  The  tendon  had  the  appearance 
of  a  bluish-white,  tough,  fibrous  cord  of  the  size  of  a  large  lead- 
pencil.  Below,  it  was  continuous  with  the  periosteum  over  the 
tibia.  The  condensed  surrounding  tissue  was  two  to  three  milli- 
meters in  thickness,  and  inclosed  the  silk  cords,  which  appeared  to 
be  as  sound  as  ever.  Microscopic  examination  of  an  excised  piece 
of  condensed  tissue  around  the  sheath  showed  that  in  the  deeper, 
and  therefore  older,  layers  next  the  silk  the  structure  was  identical 
with  that  of  a  normal  tendon.  In  the  superficial  layers  the  structure 
was  also  tendinous,  but  with  the  addition  of  scattered  ve-^d-  and 
fat-cells.  (Lange.) 

P> ridges  of  artificial  tendons  usually  heal  promptly  and 
give  fair  functional  results.  Artificial  ligaments  eight 
inches  in  length  have  been  successfully  employed.  The 
strand  of  silk  occasionally  works  out,  and,  as  it  has  been 


SURGICAL    TREATMENT    OE    POLIOMYELITIS.  361 

known  to  work  out  as  late  as  ten  years  subsequent  to  the 
operation,  it  must  be  considered  as  a  foreign  bod}-.  Adhe- 
sions may  grow,  binding  the  silk  to  the  adjacent  structures, 
and  thus  causing  limitation  of  motion;  this  is  partly  ob- 
viated by  Lange's  method  of  passing  the  artificial  tendon 
through  the  subcutaneous  fatty  tissue.  Vulpius  considers 
that  the  systematic  employment  of  artificial  tendons  is  to 
be  deprecated,  and  advocates  a  tendon-to-tendon  anasto- 
mosis as  the  first  condition  essential  to  success. 

5.  ARTHRODESIS,  OR  JOINT  STIFFENING. 

The  correct  fixation  of  a  flail  joint,  all  of  whose  muscles 
have  atrophied  after  paralysis,  can  be  secured  by  mechani- 
cal apparatus,  and  also  by  artificial  stiffening  of  the  joint. 
Artificial  ankylosis  in  a  useful  position,  secured  by  opera- 
tive interference,  is  known  as  arthrodesis.  Arthrodesis  is 
the  method  of  choice  of  the  members  of  the  working  class, 
who  can  ill  afford  the  money  and  time  required  for  the 
purchase  and  manipulation  of  expensive  mechanisms. 

The  surgical  stiffening  of  a  joint  has  proved  to  be  of 
most  value  for  certain  conditions  of  the  ankle-joint,  and 
must  often  be  utilized  for  the  flail  knee;  it  has  also  been 
used  for  the  paralyzed  shoulder.  It  is  not  advisable  to 
stiffen  the  hip-,  elbow-  and  wrist-  joint.  Fixing  a  flail 
joint  makes  it  stable,  and  thus  provides  for  a  return  of 
part  function  in  the  extremity,  and  stiffening  of  a  proximal 
joint  provides  a  fixed  point  from  which  important  unaf- 
fected muscles  of  the  hands  or  feet  take  their  leverage. 
Apparatus  can  thereafter  be  lightened  in  weight  and  finally 
dispensed  with.  The  artificially  splinted  extremity  is  there- 
after much  more  liable  to  fracture,  and  a  stiffened  knee,  of 
course,  prevents  bending  the  leg  when  sitting.  Indications 
for  the  selection  of  flail  joints:  (i)  The  very  poor.  (2) 
With  failure  of  all  other  methods.  (3)  With  no  possibility 


362  INFANTILE   PARALYSIS. 

of  regeneration  of  muscle.  (  4  )  When  certain  improvement 
outweigh^  certain  disability.  (5)  Adult  life,  or  termina- 
tion of  growth. 

Time  of  Operation. — Vulpius,  of  Heidelberg,  advocates 
an  early  operation  for  flail  joint,  considering  that  nine 
months  after  the  attack  the  operator  can  determine  that 
the  case  is  hopeless  without  surgical  interference.  Tubby, 
of  Liverpool,  is  much  more  conservative,  and  in  his  last 
volume  (1912)  advocates  waiting  for  at  least  two  years 
after  the  acute  attack  of  poliomyelitis  for  possible  restora- 
tion of  paretic  musculature.  We  are  still  more  conserva- 
tive in  our  advice  in  this  particular,  and  believe  that  clinical 
experience  justifies  us  in  this  course.  In  our  clinic  we 
have  had  numerous  cases  of  infantile  paralysis,  of  eighteen 
months  and  more,  which  have  been  passed  on  by  other 
orthopedic  surgeons  as  hopeless  without  the  continued  sup- 
port of  braces  or  operative  fixation,  in  which  we  have  suc- 
ceeded in  restoring  some  motor  function.  AYe  have  ac- 
complished this  by  discarding  all  apparatus,  whose  pressure 
frequently  interferes  with  nutrition  of  the  levators  of  the 
joint,  and  prescribing  a  systematic  course  of  physical 
therapy,  including  muscle  re-education.  It  is  our  experi- 
ence that  neglect  and  the  hasty  assumption  that  an  ex 
tremity  is  hopelessly  paralyzed  occur  in  direct  proportion 
to  the  infancy  of  the  patient  and  the  indigence  of  t lie- 
parents.  Many  cases,  however,  come  from  homes  of  pros- 
perity with  a  history  of  the  unavailing  sacrifice  of  much 
time  and  money,  in  the  hands  of  several  attendants  who 
have  agreed  that  fixation  is  the  remaining  operation  of 
election.  The  following  case  illustrates  the  foregoing:— 

Male,  Jewish  American.  8  years  of  age.  Onset  September. 
1909,  with  paralysis  of  both  upper  extremities,  which  receded  from 
right  arm,  but  left  a  left  flail  shoulder-joint.  Treated  by  several 
physicians,  who  concurred  in  recommendation  of  artificial  fixation, 
October,  1911,  at  infantile  paralysis  clinic  of  hospital,  was  found 


SURGICAL   TREATMENT    OF    POLIOMYELITIS.  363 

to  be  a  well-nourished  boy  with  a  totally  relaxed  left  shoulder. 
Six  months  after  treatment  began,  boy  could  raise  left  hand  and 
arm  extended  in  horizontal  position ;  in  one  year  the  arm  could  be 
extended  above  the  head  and  held  for  several  seconds;  the  boy 
when  last  seen  was  steadily  improving. 

.Ige  of  Patient. — Unless  absolutely  demanded  by  the 
circumstances  of  the  parents  the  mutilating  operation  of 
arthrodesis  should  be  delayed  until  the  patient  has  attained 
adult  stature  and  growth  has  ceased.  In  particular  the 
operation  should  not  be  undertaken  before  nor  during  the 
period  of  adolescence.  This  period  is  a  great  and  well- 
recognized  reconstructant  of  vitality  of  the  whole  economy, 
and  no  man  can  certainly  state  that  a  regeneration  of 
atrophic  muscles  may  not  take  place  during  the  period. 
The  orthopedist  is  further  justified  in  putting  a  case  over 
for  a  few  years  by  the  hope  that  the  interim  may  engender 
a  Miccessful  technique  for  nerve  transference  which  will 
render  a  mutilating  operation  unnecessary.- 

\Ye  have  the  support  of  Lange,  of  Munich,  who  advises 
delaying  this  operation  until  adult  life.  Tubby,  of  Liver- 
pool, and  Bradford,  of  Mass.,  do  not  operate  until  10  years 
of  age;  while  Yulpius,  of  Heidelberg,  would  operate  even 
earlier  to  secure  ambulatory  function,  although  he  does 
not  advocate  arthrodesis  of  the  upper  extremity  in  child- 
hood. 

Technique  of  Operation  of  Arthrodesis. — Asepsis  is 
to  be  maintained  throughout  this  operation.  The  joint 
should  be  freely  exposed  to  view.  The  cartilage  of  the 
articular  surfaces  is  removed  to  bony  tissue,  with  care  to 
protect  the  epiphysial  line.  Careful  approximation  should 
be  secured.  Solid  union  is  unnecessary  if  fixation  is  secured 
as  soon  as  the  skin  sutures  are  in.  Plaster  dressings  are 
left  in  place  for  two  weeks,  when  the  cutaneous  sutures 
are  removed,  and  thereafter  for  from  three  to  six  months. 


364  INFANTILE    PARALYSIS. 

6.  NERVE   TRANSFERENCE    AND    NERVE   GRAFTING. 

The  clamor  of  a  greatly  augmented  army  of  paralytics 
has  recently  stimulated  research  into  methods  for  their 
relief.  This  is  particularly  true  of  the  work  being  done  in 
the  great  European  clinics,  where  in  the  past  ten  years 
and  more,  particularly  in  the  past  five  years,  a  constant 
investigation  has  gone  forward  in  methods  which  may 
make  practical  the  regeneration  of  paretic  muscle,  with  a 
renewal  of  motor  function.  The  paralysis  of  poliomyelitis 
is  most  often  limited  to  a  single  muscle  group  or  the  muscles 
supplied  by  an  individual  nerve-trunk,  while  the  contig- 
uous nerve-trunk  and  the  muscle  groups  innervated  by 
it  remain  unaffected. 

The  regeneration  and  budding  of  a  healthy  peripheral 
nerve-trunk  which  had  been  severed  accidentally  or  during 
an  amputation  has  long  been  recognized,  and  many 
operators  have  endeavored  to  utilize  this  characteristic 
by  grafting  a  portion  of  the  healthy  nerve-trunk  into  the 
non-functionating  nerve-trunk  of  a  partially  paralyzed 
extremity.  This  operation,  in  one  or  two  instances,  has 
resulted  in  a  speedy  return  of  function  to  the  paretic 
muscle;  in  many  cases  there  was  partial  improvement  after 
eight  or  more  months,  while  in  50  per  cent,  of  the  cases 
there  has  been  no  return  of  function. 

Theoretically,  this  operation  of  nerve  anastomosis. 
offering  as  it  does  a  possibility  of  regeneration  to  the  spent 
nerve  and  the  restoration  of  motor  power  to  the  paralyzed 
muscle,  would  be  the  operation  of  choice,  \\~hile  it  cannot 
be  recommended  until  an  improved  technique  has  greatly 
augmented  the  possibility  of  a  successful  result,  the  fact 
that  one  or  two  cases  have  given  immediate  and  brilliant 
returns  lends  color  to  the  hope  that  in  a  very  few  years  it 
may  be  the  operation  of  election. 


SURGICAL   TREATMENT    OF    POLIOMYELITIS.  365 

A  series  of  cases  have  been  operated  and  reported  by 
Tubby,  of  Liverpool;  Spitzy,  of  Vienna,  and  Vulpius,  of 
Heidelberg".  Vulpius  and  his  clinical  assistant,  Stoffel, 
have  made  an  extended  study  of  the  anatomic  basis  for 
such  nerve  transplantations.  They  were  able  to  demon- 
strate that  the  fibers  which  innervate  particular  muscle 
groups  occupy  a  certain  relative  position  and  pursue  a 
certain  relative  course  in  the  nerve-trunk  of  conduction, 
and  that  this  arrangement  was  almost  constant  in  numer- 
ous preparations  made  by  Dr.  Stoffel. 

Any  operator  who  desires  to  make  use  of  neuroplasty 
will  wish  to  be  familiar  with  the  results  of  the  Stoffel 
demonstrations.  Dr.  Vulpius's  summary  of  the  present 
stage  of  neuroplasty  is  as  follows  :— 

"The  operation  (neuroplasty)  is  not  as  satisfactory  in  practice 
as  it  is  attractive  in  theory.  The  results  that  have  been  obtained 
after  much  laborious  work  are  certainly  promising,  but  do  not 
compare  in  point  of  efficiency  with  those  of  tendon  operations.  Not 
only  does  the  latter  insure  the  power  of  recovery  in  the  muscles,  but 
it  is  a  very  reliable  proceeding,  and  one  that  justifies  us  in  giving  a 

fairly  confident  prognosis  to  the  patient  and  his  relatives 

Where  time  and  money  are  of  little  moment  neuroplasty  may 
reasonably  be  employed,  but  it  is  unsuitable  for  the  bulk  of  hospital 

patients Neuroplasty  may  be  termed  the  opcratio  diritnni, 

because  it  entails  an  expenditure  of  time  and  money,  with  fre- 
quently a  smaller  chance  of  success.  The  expenditure  is,  however, 
not  unavailing,  for  the  method  represents  a  new  line  of  advance, 
and  it  is  our  privilege  and  our  duty  to  render  it  a  practical,  safe, 
and  successful  method.  The  task  is  a  difficult  one,  but  the  problem 
is  encouraging,  and  the  successes  that  have  already  been  obtained 
render  our  ultimate  success  certain."  ("Treatment  of  Infantile 
Paralysis,"  Yulpius.) 


INDEX. 


Acute  attack,  general  features  of.  \17 

symptoms.   127 
Acute  bulbar  type,  128 
Acute  stage,  reflexes  during,  192 
Adolescence.  73 
Adults,  73 
Age,  2,  71 
Analgesics,  273 

Anatomic    investigation    of   cases,  of 
epidemic  acute  polioencepha- 
litis,  164 
Anatomy,  pathologic 

anterior  root   fibers,  92 

blood,  99 

brain,  95 

cerebellum.  95 

brospinal   fluid,  86 

cerebrum  and  central  ganglia,  97 

cord,  87 

digestive  system,  98 

kidneys,  99 

liver 

lungs,  98 

medulla  and  pons,  93 

meninges  of  brain  and  cord,  84 
dura,  84 
pia-arachnoid,  85 

peripheral  nerves,  93 

posterior  root  fibers,  93 

spinal  ganglia,  93 

spleen,  98 

visceral  lesions,  99 
Anatomy,  pathologic,  of  chronic  stage, 
"lOl 

cord,  spina'.  101 

joints,  102 

muscles,  101 

skeleton,  102 

tendons,  101 

Animal    and    man,    coincidental    epi- 
demic paralysis  in,  7 


Animal,  coincidental  paralysis  in; 
chickens,  examinations  of 
paralyzed.  12 

dog,   13.   14~ 

pigs   and   chickens,    12 

sheep,  14 

Anterior  root  fibers,  pathologic  anat- 
omy of,  92 
Antipyretics,  272 
Antiseptics,  internal,  254,  273 

nasal,  255 

Arrested   type.    12S.    130 
Ataxia,  Friedreich's,  204 
Atrophy,  232 
Aura  of  attack.  105 

of  onset.   1S7 
Autointoxication,  216 
Autopsy,  79,   164 

convolution,   right   postcentral,   82 

cord,  81 

lobe,  right  olfactory,  S2 

medulla,  lower,  82 

Bacterium,  Geirsvold's.  21 
1 '.arn-rty.  42,  244 
I'.edbug.  48 

coincidental  presence  of,  and  polio- 
myelitis, 57 

destruction  of,  by  fire,  249 
hydrocyanic  acid  gas  method  of 

destroying,  247 
local  application,  249 
sulphur  fumigation,  248 
B  flat,  48 

Bichloride  of  mercury,  269 
Biting  fly.  42 
Blood.  99 

sucking  insects  parasitic  to  man,  244 
Brain,  95 

Breathing  exercises,  328 
Bronchopneumonia,   211 

(367) 


368 


1XDEX. 


Cardiac  pain  and  involvement,  149 
Causes,  predisposing,  69 

adolescence,  73 

adult>.    7.1 

age   incidence,  71 

dentition,  period  of.  73 

factors      increasing      virulence     of 

virus,  78 
which  may  increase  susceptibility 

of  host,  75 
rainfall,  77 
season,  77 

geographic  distribution 

race,  69 

sex,  74 
Cerebellum,    pathologic    anatomy    of, 

95 

Cerebral  type,   195 
Cerebrospinal  fluid.  86 
Cerebrum  and  central  ganglia,  97 
Cervical  tension,  188 
Chemotoxin,  21 
Chicken-pox.  211.  212 
Chickens,  examination  of  paralyzed,  12 
Chinchbug,  48 
Cholera  morbus,  207 
Cimex  lectularius,  48 

burden  of  proof  against.  55 
geographic  range  of,  55 
Circulatory  system,  109 
Classification  of  150  cases,  2 

age,  2 

digestive  system,  3 

distribution  of  paralysis,  3 

month   of  occurrence,  2 

other  cases  in  house,  2 

reclassification,  128 

sex.  2 

skin,  3 

symptoms  of  onset,  2 

urinary  organs,  3 
Common   carriers,   251 
fumigation   of,  251 
Constipation,   192 
Contact  contagion,  251 
Convolution,  right  postcentral,  82 
Cord,  81,  87.  101 


Counterirritatkm,  270 

Cutaneous  rash,  193 

Dentition.  73,  215 
Diagnosis,  differential.  196 
autointoxication.  216 
bronchopneumonia.  211 
chicken-pox,  211.  212 
cholera  morbus.  2<>7 
dentition.  215 
diarrhea,   summer.   207 
diphtheria,    205 
eclampsia,  217 
enteritis,  207 
Friedreich's  ataxia.  2(>4 
grippe,  summer.  211 
heat  prostration.  221 
hemorrhage,  cerebral.  222 
influenza,  211 

intussusception   of  bowel.   22\ 
measles,  211,  212 

German.  211.  212 
meningism    in    infectious    diseases, 

201 
meningitis,  196 

epidemic   cerebrospinal,    11>S 

suppurative,  199,  201 

tuberculous,  199 
myelitis,  acute  transverse.  2l»4 
other  diseases,  203 
paralysis,   acute   infectious  diseases 
without,  207 

agitans,  204 

diphtheritic.  205 

epidemic,  205,  206 

hysterical,  207 

obstetrical,  206 

tuberculous  spondylitis   with,  206 
paralytic    conditions,    diseases    pre- 
senting. 205 
paratyphoid,  209 
pneumonia,  211 
pseudoparalysis  of  scurvy.  2i>7 

syphilitic,  205,  206 
ptomaine  poisoning,  216 
rabies,  214 
rachitis.  219 


IXDEX. 


369 


Diagnosis,  rheumatism,  acute,  articu- 
lar, and  muscular,  209 
muscular.  21(1 
scarlet  fever,  211,  212 
scurvy,   pseudoparalysis   of,   207 
spondylitis,  tuberculous,  with  paral- 
ysis, 206 

sprained  ankle,  222 
sunstroke,  221 

tetanus  with  convulsions,  213 
tonsillitis,  210 
trichiniasis,  218 
tuberculosis  of  joints  with  fixation 

from  pain,  219 
i  Jiarrhea,  summer,  207 
Diet.  278 
!  ligestive  system,  3,  98 

pathologic  anatomy  of. 
tract,   116 
Diphtheria,  205 

Distribution  in  United  States,  5 
Dog,   13,   14,  243 
Dura,   pathologic   anatomy  of,  84 

Echinacea,   276 
Eclampsia,  217 

Electrotherapy,  285 

combined      galvanic      and      faradic 
early,  293 

high-frequency        current        during 
acute  stage,  288 

massage  and  electricity.  301 

<tf    chronic    paralytic    and    atrophic 
stage,  298 

pain  during,  305 

reaction  of  degeneration,  303 
Elimination,  267 
Encephalitic  type,   128,  156 
Encephalitis  cerebelli.  163 

of  midbrain  and  connections,  163 

thalamic,   164 
Endocarditis.   150 
Enteritis,  207 
Epidemic    paralysis,    coincidental,    in 

animal  and  man,  7 
Epidemic,  the  \Yisconsin.  1 
Epidemics  and  pandemics,  1,  16-20 


!   Epidemics   and   pandemics,    mortality 

rate  in,  223 
Epistaxis,   193 
Ergot,  272 
Etiology.   21 
barn -fly,  42 
bedbug,  48.     (See  also  ciinc.r  Icctu- 

larius,  below.) 
coincidental     presence     of,     and 

poliomyelitis,   57 
B   flat.   4S 
biting  fly.  42 
chemotoxin,  21 
chiuchbug,  48 
cimex  lectularius,  48 

burden  of  proof  against,  55 
geographic  range  of,  55 
Dixon's  protozoon,  25 
epidemiologic     endorsement      of, 

29 

Flexncr's   filterable    virus.   23 
Giersvold's    bacterium     or    micro- 
coccus,  21 
hypotheses  of,  21 
mahogany  flat,  48 

organism  of,  characteristics  of,  34 
protozoa,  27 

means    of   transmission   of,    out- 
side of  the  body,  28 
successful      cultivation      of     the 
pleomorphic,  of  poliomyelitis, 
32 

rain-fly,  42 
sporozoa,  27 
stable-fly,  42 
stomoxys   calcitrans,  42 
transmission   by   stable-fly,  45 
contact,  64 

from  animal  to  man,  41 
from  man  to  man.  41 
method  of,  41 
through  dog,  65 
to  monkey,  34 
wall  louse,  48 
Exercises,  breathing,  328 

therapeutic,  before  a  mirror,  314 
Exposure,  history  of,  194 


370 


INDEX. 


First  aid.  261 

Flea.  250 

Flcxner's   filterable   virus.  23 

Flies,  methods  for  destruction  of,  245 

Formalin,   273 

Frauenthal  brace.  359 

Friedreich's  ataxia,  204 

Frontal  area,   162 

involvement,  with  resulting  men- 
tal defect.    1<>5 

Geirsvold's  bacterium  or  micrococcus, 

21 

Gelsemium.   272 
Genitourinary   system.    118 
Grippe,  summer,  211 
Growth  of  long  bones,  arrest  of,  231 

IK-at  prostration,  22\ 
Hemorrhage,  cerebral.  222 
Hydrocyanic     acid     gas     method     of 

destroying  bedbugs,  247 
Hydrotberapy.  280 

warm  water  bath,  283 
Hyperesthesia,   187 
Hyperpyrexia.   190 
Hypertrophy.  232 

Incubation.    104 

Influenza.  211 

Institutional    type,    rapidly    fatal,    129 

Intussusception    of   bowel,   221 

Isolation,  263 

Joints.    1(12 

Kidneys,  pathologic  anatomy  of,  99 

Light,  exclusion  of,  266 

Liver,   pathologic   anatomy   of.  98 

Lobe,   right  olfactory.  S2 

Local  depletion,  271 

Lumbar  puncture,  27<  > 

Lungs,  pathologic  anatomy  of,  98 

Mahogany   flat,  48 

Massachusetts,   infantile  paralysis  in, 
76 


Measles.  211.  212 

German.  211.  212 
Mechanotherapy,   330 

ankle-joint,  350 

mechanisms  for  contrac-tur^.  349 

supportive   apparatus,  33' ' 
Medication.  2<>7 

Medulla    and    pons,    pathologic    anat- 
omy of,  93 

lower.  82" 

Meninges   of  brain    and   cord,   patho- 
logic  anatomy    of.   84 
Meningism.    125 

in  infectious  diseases.  2n 
Meningitic  type.    12S 
Meningitis,   12o.   l')i> 

epidemic    ccrebrospinal.    1'>S 

suiipurative.    199,  201 

tuberculosis.    199 
Mental    state.   121 
Micr<  K  <  ieirsvold's.   21 

Monkey,  transmission  to.  34 
Mortality  rate  in  epidemics,  JJ3 
Mosquito,   250 

les,  101 
Myelitis,   acute   transverse,  2l>4 

transverse.    14S 

Necropsy.    164 

Neural  type,   129 

Nose  and  throat,  disinfection  of,  254 

<  Kvipital   area,   Id2 
Occurrence,  month  of.  2 
Onset.    10S 
aura   of.    1S7 

Pain.    123 

and   tenderness,   124 
Pandemics,  1,  16-20 
Paralysis,    acute  .infections    di 
without.  2n7 

agitans.  204 

diphtheritic,   2n5 

distribution   of,   3,    22'' 

epidemic.   205,   206 

extent.   22S 


IXDEX. 


371 


Paralysis,  hysterical.  3*7 

impending,     pro^rosive.     and     re- 
gressive 22 
obstetrical.  206 
residual.  229 

treatment  of  progressive  ascending 
or  descending,  with  impend- 
ing paralysis  of  respiration, 
279 

tuberculous  spondylitis  with.  2<*> 
Paralytic     conditions,     diseases     pre- 
senting, 2<  b 
Paratyphoid.  2(19 
Pathology,   79 

Peripheral    nerves,   pathologic    anat- 
omy of,  93 
Physical  therapy,  3<>7 
massage,  308 

massage  and  passive  motion.  3(>7 
resistance  exercises,  308 
Physician,   prophylaxis    for,   259 
Pia-arachnoid,     pathologic     anatomy 

of. 

and    chickens,    12 
Pneumonia,  211 
Polioencephalitis  inferior,  Io3 

superior,  162 
Position,  2'  4 
Posterior      root      fibers,      pathologic 

anatomy  of,  93 

Prevalence  of  cases  in  United  States,  6 

•sis  as  to  life  and  disability.  223 

arrest  of  growth  of  long  bones  and 

amount  of  shortening.  231 
atrophy,  232 
yrave,  235 
hopeful.  235 
hypertrophy,  232 
mortality  rate  in  epidemics.  223 
paralysis,   distribution,  229 
extent,  228 

impending,    progressive,    and    re- 
gressive, 
residual.  229 

recovery,  time  of.  232,  233 
sporadic  cases.  22i> 
Prophylaxis  and  immunity.  236 


Prophylaxis    and    immunity,    commu- 
nal, individual,  physician,  236 
communal,  236 

and  the  local  health  board.  239 
blood-sucking  insects  paralytic  to 

man.  J44 
barn-fly.  244 
bedbug,  246 

methods    for   destruction   of, 

246 

hydrocyanic  acid  gas,  247 
sulphur,  248 
tire,  249 

local   application,   249 
flea.  250 
mosquito,   25i> 
rain-fly,  244 
stable-fly,  244 

methods    for    destruction    of 

flies.  245 
contact  contagion   from  common 

carriers,  251 

fumigation     of     the     common 
carriers  of  modern  trans- 
portation.  251 
the   human   case  and,  237 
the  paralytic  animal  and,  241 

the  dog,  243 
individual,    252 

disinfection   of   nose   and   throat, 

254 

nasal  antiseptics,  a  warning.  255 
internal  antiseptics,  254 
medication,   254 
for  the  physician,  259 
Protozoa,  27 
means  of  transmission   of,  ontside 

of  the  body,  28 

successful   cultivation   of  the   pleo- 
morphic,  of  poliomyelitis.  32 
Protozoon,   Dixon's,   25 

epidemiologic  endorsement  of.  29 
Pseudoparalysis  of   scurvy,   207 

syphilitic.  205,  206 
Ptomaine  poisoning,  216 
Pulse  rate,  increased,  191 
Purpura.   193 


372 


INDEX. 


Quinine,    276 

Rabies,  214 

pleomorphic  spirochete  of.  30 
Race,  69 
Rachitis,  219 
Rainfall.   77 
Rain-fly,  42,  244 
Rash,  cutaneous,  193 
Reclassincation,   128 
Recovery,  time  of,  232,  233 
Reflexes,    126 

during  acute  stage,  192 
Resorption,  271 

Respiration   rate,  increased,   190 
Respiratory  system,  114 
Rest,  264 

Rheumatism,     acute,     articular,     and 
muscular,  209,  210 

Scarlet  fever,  211,  212 

Scurvy,  pseudoparalysis  of,  207 

Season,  77 

Sedatives,  273 

Serologic  treatment,  278 

Sex,  2,  74 

Sheep,  14 

Skeleton,  102 

Skin,   3,    119 

Spinal  fluid,  examination  of,  193,  235 

Spinal    ganglia,    pathologic    anatomy 

of,  93 

Spinal  myelitic  type,  128,  13S 
Spirochaeta  pallida,   32 
Spirochete  of  rabies,  pleomorphic,  30 
Spleen,  pathologic  anatomy  of,  98 
Spondylitis,  tuberculous,  with  paral- 
ysis, 206 
Sporozoa,  27 
Sprained  ankle,  222 
Stable-fly,  42,  244 
Stage,  preparalytic,  diagnosis  in,   186 

aura  of  onset,  187 

cerebral  type,  195 

cervical  tension,  188 

constipation,  192 

cutaneous  rash,  193 


Stage,      preparalytic.      diagnosis      in; 

epistaxis,  193 
exposure,   history   of,    194 
hyperesthesia,  187 
hyperpyrexia,   190 
motor  symptoms  of.  234 
pulse  rate,  increased,   191 
purpura,  193 

reflexes  during  acute  stage,  192 
respiration  rate,  increased,  190 
spinal   fluid,  examination   of.    193 
sweating,   193 
urine,  retention  (if,  193 
vomiting.    192 

Stage,  preparalytic,  treatment  of,  260 
first  aid,  261 
general,  263 
diet,  278 

exclusion  of  light,  2'>'> 
isolation,  263 
lumbar  puncture  276 
medication,  267 
analgesics.  273 
antipyretics,  272 
bichloride  of  mercury,  269 
counterirritation,   270 
elimination,  267 
ergot,  272 
gelsemium,  272 
internal  antiseptics.  273 
echinacea,  276 
formalin,  273 
quinine.   276 
local  depletion,  271 
resorption,  271 
sedatives,  273 
strychnine,   268 
vasomotor  control,  271 
position,  264 
rest,  264 
serologic,  278 
Stomoxys  calcitrans,  42 
Strumpell's  paralysis,   \<>2 
Strychnine,  268 
Sunstroke,   221 

Susceptibility  of  host,   factors  \\hirli 
may  increase,  75 


INDEX 


373 


Sweating,  193 
Symptomatology,  general.   104 

attack,  acute,  general  features 
of,  127 

aura   of   attack,    105 

circulatory  system,  109 

cutaneous   system,   119 

digestive  tract,  116 

genitourinary  system,   118 

incubation,    104 

meningism,  125 

meningitis,  126 

mental  state,  121 

onset,   108 

pain,    123 

and   tenderness,    124 

reflexes,   126 

respiratory    system,    114 

temperature,   112 

trauma,    106 

Symptomatology  of   special   types   of 
acute  poliomyelitis,  128 

acute  ascending,  150 

affecting  superficial  and  deep 
muscles  of  neck  and  extremi- 
ties, resembling  polyneuritis, 
175 

arrested  type,  130 

etiologic    identity    of    abortive 
(arrested)        and       paralytic 
forms,  132 
frequency  of,  134 
symptoms,  136 

bulbar-pontine  type,  acute.  154 

cardiac  pain  and  involvement,  149 

chorea,  178 

encephalic  type,  156 
classification   of   symptoms   of, 
162 

endocarditis,   150 

herpes  zoster,  177 

Landry's,   150 

meningitic  type.  1/0 

neural   type.    173 

predominant  acute  ataxia  type, 
165 

progressive,  rapidly,  150 


Symptomatology  of  rapidly    fatal   in- 
stitutional disease,  179 
reclassification,  128 
acute  bulbar,   128 
arrested   type,   128 
encephalic  type,   128 
meningitic  type,  128 
neural   type,    129 
rapidly    fatal    institutional    dis- 
ease type,  129 
spinal  myelitic  type,  128 
recrudescence,    184 
spinal  myelitic,   138 

distribution  of  paralysis,   141 
spontaneous  regression,   148 
transverse  myelitis,  148 
two  attacks  in  same  case,  183 
Symptoms  of  onset,  2 
Syphilitic  pseudoparalysis,  205,  206 

Temperature,   112 
Tendons,    101 

Tetanus   with    convulsions,   213 
Tonsillitis.    210 
Transmission  by  stable-fly,  45 
contact,  64 

from  animal  to  man.  41 
from  man  to  man,  41 
method  of,  41 
through    dog,   65 
to   monkey,   34 
Trauma,  106 

preceding  poliomyelitis,   106 
Treatment  of  preparalytic  stage.    (See 

stage,  fre  paralytic.} 
of    progressive    ascending    or    de- 
scending  paralysis    with    im- 
pending paralysis  of  respira- 
tion, 279 
surgical,  351 
arthrodesis,  361 
artificial   tendons   and   ligaments, 

358 

joint  stiffening,  361 
muscle  and  tendon  transference, 

354 
nerve  grafting,  364 


374 


IXDEX. 


Treatment      of      preparalytic 

transference, 
tendon  lengthening,  352 

shortening:.  354 
Trichiniasis.   218 
Tuberculosis   of   joints   with    fixation 

from  pain,  219 
Type,   cerebral,    195 
Types,    special,    symptomatolc  _ 
US 

United  States,  distribution  ni,  5 
prevalence  of  cases  in,  6 


I'rinary  origan-.  3 
Trine,   retention   of,    193 

Vasomotor    control.    271 

\  irus.     factors    increasini;    virulence 

of. 

Flexner's   lilterable.  23 
X'isceral   lesions,  99 
\Omitinir.   192 

\\'all    louse.    4S 

\\  isconsin.  e[)ideinic  in,   1 


Date  Due 


PRINTED   IN    U.S.*.  CAT.      NO.      24       161 


°°°7?, 


Wu 


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191*1 

Frauerthal,  Henry  W. 

l  of  infantile  paralysis 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


